FACE BOW

HISTORY :

If we wish to know something about face bow, how this instrument is used and the significance of its application a short historical survey of the
ideas connected with these problems, and the working 'methods and instruments that they have given rise to, will give us clear picture of the features to
be remembered in this aspect.

About mid 18th century it began to be realised that in fabrications of complete dentures it was important to mount the casts inthe articulator in a given
positional relation to the condylar elements. According to Bonwill, 1860 the distance from he center of each condyle to the median incisal point of the lower
teeth is 10 cm and he advocated this measurement to be followed while mounting but he did not mention however at what level (vertically) the occlusal
plane be paced in relation to condyal mechanism. It appears that he advised the casts to be mounted midway between the upper and lower parts of the
articulator.

In 1866 an English dentist by name Balkwill devised methods that were improvement on those proposed by Bonwill.

Balkwill demonstrated on apparatus with which he could measure the angle formed by occlusal plane and the line joining condylar centers to the
incisal point of the lower teeth and the angle varied from, 22° to 30°.

An other method for localizing the casts in the articulator was constructed by Hayes in 1880 and the apparatus was called caliper. However again there
was no proper orientation possible.

Then in 1890 walker invented Clinometer with which it was possible to obtain a good position of the cast in articulator. He used mainly this
instrument as instrument for condylar inclination measurement device. A little later Gysi about the turn of the century developed an instrument similar to a
facebow primarily to record position of the condyles however, it could be used to mount casts. But the credit goes to Snow for inventing a Actual Facebow
on which most of the present day facebows are based. Snow introduced the facebow in 1899 and patented it in 1907.

In 1914 Dalbey introduced the use of ear type of facebow but it was not until late 60's the ear type did gain popularity.

We are justified in staling that snow's facebow inspite of its very simple construction was Epoch making in prosthetic dentistry. Since the introduction
of Snow's apparatus, no fundamental changes have been made in the face bow design. Because snow determined the position of the casts in the articulator
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not only in regard to distance of the mid incisal point from the condyles but also the other points of the occlusal plane were given the correct relationship in
relation to condyles.

PRINCIPLES OF FACE BOW USE:

The movements of the teeth are results of the rotation and sliding made by the condyles. The better the casts on the articulator duplicate the distances
to the rotational condylar centers, the less the potential errors produced by difference in the arcs of closure of the mandible and the articulator.

The use of facebow is an integral part in procedures in analyzing and studying occlusion, developing occlusion for complete dentures and other
restoration.

The occlusal plane is related by making it parallel to a horizontal plane so that it easier to relate it the articulator.

Snow recommended that the occlusal plane be made parallel with a plane extending from the bottom of the glenoid fossa and passing through the
anterior nasal spine.This plane cannot be determined directly on a living persons but it approximately, corresponds With a line drawn from the upper parts the
Tragus to the lower edge of the Nostril or Alatragal line. This plane in European literature is referred as camper's plane, in Americal literature it is referred so
as Bromell's plane. Gysi and kohler used a plane called as prosthetic plane which extends from the lower part of the tragus to the Ala of the nose. Wads-worth
employed a different plane which from the condyle area and runs at right angles to a line that connects the most prominent points of the chin and forehead.

Over recent years, there has been a growing tendency to employ a plane (i.e.) the Frankfort horizontal plane which is usually parallel to the floor when
an individual is in an upright position. Cephaornetrically the Frankfort's plane is described as a horizontal plane that passes through the right and left portion
2 meatas) and the orbitale (the lowest point on interorbital rim).
(the mid point on the upper margin of external auditory
 The Horizontal plane forms a plane which is called as the Axis-ORBITAL plane. This plane formed by the two posterior points of reference and the
one anterior point of reference which is usually the infraorbital notch indicated by the pointer fixed on the face 'bow and the posterior points of reference are
those where the condylar rods are placed thus when utilizing the two posterior (points) and anterior points the occlusal plane is related to the face bow and
through the face bow transfered on to the articulator.

In the articulator there is a condylar plane established by the condylar spheres and a indicator for the anterior point of reference the condylar rods
approximating the condyles through it the hinge axis are attached to the centre at the condylar spheres of the articulator.

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Principle face bow use:

The prosthesis or indirect restorations that are planned and fabricated with help of articulators should have the same relationship as they have with
articulator’s axis of opening as well as the patients mandibular arc of movement.

Since it is practically difficult to orient the mandible to the articulator, the maxillary cast is related to the articulator with same relationship with the
existing relationship between maxillary and condyles of TMJ which is center of mandibular movements, the mandibular cast is related to maxillary cast
which in turn is oriented in the articulator. To accomplish this act of orientation the device face bow is utilized.

Before we (study) know more about the facebow and its use a brief description about the terminal hinge Axis will help us in better understanding of
the face bow.

The terminal hinge axis is an imaginary axis around which the condyle can rotate without translation and this axis is assumed from which all the
mandibular movements of opening and closing take place. The THA is the most retruded hinge position and is significant because it learnable, repeatable
and recordable that coincides with the centric relation. The limits of the hinge movement in this position is about 12°-15° at condyles or 19-21 mm in the
incisal region.

The condyles are in a definite position in the fossa during the rotation. Snow recognised the importance of this axis and to transfer this axis to the
articulator led to development of facebow and in 1921 McCollum, Stuart and others reported the first method of transferring this axis. Since then many
have put forward views that are very diverse from each other.

Sloane stated

"The mandibular axis is not a theoretical assumption but difinitely demonstrable biomechanical fact. It is the axis which on the mandible rotates in
an opening and closing function when comfortably but not forcibly retruded."

"The hinge position or terminal hinge position is that position of mandible from which or in which hinge movements of a variable wide range is
possible.

But contrary to them Brekke, Trapozzano and Lazzari and Lucia questioned existence of the single hinge like axis of rotation for mandible since the
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ideal mechanical set up is never found in living tissues.
 Controversy arises as to the presence of single relationship of TH position to entire portion. There are differences in concepts and interpretations of the
findings. These differences in findings are understandable and these seems to be general agreement that when the mandible is in centric relation the
mandible is in its most posterior unstrained position from which a trained individual can voluntarily open and close the mandible in hinge movement. Since
it is a repeatable and recordable position it is a point of return.

Therefore we strive to capture this imaginary axis and transfer this to the articulator and depending upon how accurately the face bow capture and
transfer this to articulator led to the coining of words like Kinematic face bow and Arbitrary face bows.

The occlusal plane or the wax rim is related to the TMJ by using a horizontal plane and this relationship is transferred to the articulator using a
facebow register the GLENO MAXILLARY.

Relationship in three plane of:

o Anterio-posterior sagital plane

o Transvers or frontal
o Vertically

The maxilla is related to a horizontal plane usually formed by 3 points of references.

Two posterior points of reference

One anterior point of reference

If the inaxillary cast is positioned without the correct maxilla hinge axis relationship arcs of movement in the articulator will occur which are
different from those of patient.

Occlusion that is restored to an incorrect arc of closure will have interceptive and deflective tooth contacts.

Such contacts are undersirable and contribute to:

o Periodontal problem
o Muscle spasm 5
 o TMJ pain
o Loss of supporting bone

Location of hinge axis was discussed by Campion first time told that axis of opening should coincide with the articulator axis.

Theoretically unless the extra THA is located and transferred the inter occlusal space used for recording in jaw relations will induce errors in casts
mounted on articulators. The error produced may not have serious consequence in removable prosthesis with non-rigid attachments in such conditions the
intended tolerances and mobility of the supporting tissues make the precise location of THA a exercise with no great advantages. On the other hand fixed
and removable prosthesis of rigid attachments demand close tolerances in cusp path ways.

Facebow Transfer:

Use of kinematic face bow : The technique for locating the axis for dentulous and edentulous patients is same except for the mode of attachment of
the clutch to the mandible. The clutch directly cemented on the teeth and in case of edentulous condition clutch is attached to mandibular wax rim and the
chin clamp is used to stabilize the mandibular denture base because of the instability and soft tissue mobility, inaccuracy creep in which defeat the purpose of
axis location. The patient is trained to make a limited opening and closing movements of about 19-20mm in insial region within the rotational movement of
the condyles. These points are directly marked on the skin or flag or grid with graph paper placed on it and this distance is measured from the tragus and is
used as the posterior reference point and the facebow transfer is done in usual means.

In case of Arbitrary type facebow the posterior points are selected on a anatomical average of l3mm anterior to the tragus on a line from tragus to the
outer cantus of the eye and the fork is attached to the maxillary teeth or wax rim. The fork is either inserted in the rim or a index is used. The condylars
(elements) rods are adjusted till the fork is centered and the pointer for third point of reference of orbital pointer or the nasion relator is adjusted and once
all the locknuts or secured the facebow should support by itself without any movement than the condylar lock nuts are released and the face bow transferred
to the articulator with the condylar rods approximating the condylar spheres of the articulator and the pointer pointing to the built in orbital indicator and the
cast is placed in the record base and mounted.

Thus the plane of occlusion when viewed on the articulator will be similar to that of the patient in an upright position and the occlusion plane is
placed in a similar, relation in the articulator as that exists in the patient's mouth.

Description of Facebow :

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The facebow consists of 'U' shaped frame or assembly i.e. large enough to extend from the region of the TMJ to a position 2-3 inches in front of the face
and wide enough to avoid contact with sides of the face. In the condular region there are condylar rods with graduation extending from the main assembly
which are placed over the posterior reference points, the reading the condylar rods help us to center the facebow. Once the facebow is adjusted there are
locknuts that are tightened. The part of the assembly that is attached to wax rim is called bite plane or fork through the stem or yolk. The fork is attached
to the main frame and there are pointer for the third point of reference like orbital pointer or nasion relator.

The facebow or hinge bow for kinematic is also similar in construction except that instead of the fork attached to maxilla it is attached to the mandible
and there are attachments where the flages or grids with graph paper are attached to frame which either attached to the maxi, teeth or held by head straps or
worn as spectacles. The clutch or the fork on the mandible in case of edentulous patiet is stabilized using a chin clamp.

The arbitrary axis of rotation as set forth by Snow, Gilmer, Hanau, Gysi and others of 13mm anterior to the tragus on the tragus-canthus line very
close to an average determined axis.

The procedures locating hinge axis calls for rather lengthy and difficult procedure, which require use of a large and bulky apparatus, which pose
problems of attaching the apparatus to the mobile mandible securely and this problem is more compounded in edentulous jaws where the soft tissues and
mandibular denture bases are unstable.

This lead Craddok and Symmons in 1952 to state that "search for the axis in addition to being trounlesome is of no more that academic interest for it
will never be found to lie more than few milimeters distant from the assumed center of the condule itself. This can be done palpation 10-13mm anterior to
tragus.

The T.H.A. is not only difficult to locate but also difficult to relocate the same point of axis. Kenneth and Fein-Stein attempted to locate the axis
and were successful only in relocating it within a radius of 2mm.

Borjh and Posselt could relocate it within 1.5mm.

USE OF F.B. AND RELATION TO THE ARTICULATORS REFERENCE POINTS

One recommended method of positioning, the maxillary cast vertically in Hanan articulator is to relate the maxillary cast with the F.B. still attached to the
articulator till the maxillary central incisors .edges or the maxwax rim are aligned to the level of Incisal Reference Notch. 30mm below the Horizontal
condylar plane described by the centers of the condyles and the infra-orbital indicator, unfortunately there is no Anatomic relationship between the anterior
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reference point of orbital and I. R. Notch in other words the 30mm is not the correct distance between orbitals and maxi incisal edges. There are other
incisal reference notches placed 37, 54 and 47mm below the condylae place. But according to Gonzalers and kingery the centre of the condyle is 7mm below
the porion which forms the frankforth horizontal plane and therefore the axis-orbital plane should be placed 7mm below to set a proper parallelism and
therefore the infraorbital foramina should be used as anterior points of reference.

POSTERIOR POINTS OF REFERENCE

Often the posterior points are located by measuring prescribed distances from skin surface landmarks. Some of the commonly used posterior
points were shown by beck to be clinically near the hinge axis. He concluded that pergstorm point followed by beyron point were most frequently close to
hinge axis. It is known that balanced occlusion is necessary for the stability of the dentures and for the health of the oral tissues. An accurate place of
orientation does appear to be essential step in C.D. fabrication.

An error of this size may not have serious consequence in removable prosthesis with non rigid (connectory) attachments, in such conditions the
intended tolerances and mobility of the supporting tissues make the precise location of the Hinge axis a en... with no great advantage on the other hand
fixed and removable prosthesis with rigid attachment demand close tolerances in cusp path ways.

Verifications of the mandibular cast portioning by use of inter occlusal records made at increased vertical dimensions of occlusion will be difficult if
not impossible when the interocclusal records are made at same thickness. Changes in vertical dimensions of occlusion.

Bergstorm point : 10mm anterior to the centre of spherical insert for the auditory meantus and 7mm below the Frankforth H. plane. Beyron point
13mm anterior to the posterior margin of the tragus of the ear on a line from the centre of the margins to the corner of the eye.

The selection of the (anterior) points of reference is useful so that different maxillary casts of the same patient can be positioned in the articulator in
the same relative position. The points give the procedure the value of constant determination and also reduce time with complicated time consuming
recording techniques such as pantographic tracings to repeat the records each time the technique calls for a new casts. For this reason it is important to
identify the mark permanently or be able to repeatively measure a anterior reference, point as well as the posterior points of reference.

Selection of Anterior Point of Reference

1. Obritale : In the skull orbitate is the lowest point on the infraorbital rim. On a patient it can be palpated through overlying skin and orbitate and
the the posterior points that determine the horizontal axis is defined as the axis - orbital plane. Practically the axis orbitory plane is used because of the
ease of locating and points easy to understand.
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 This plane can be transferred to articulator with the help of the orbital pointer and indicator on the articulator.

2. Orbitale minus 7Tnm : The frankfort ' s horizontal plane passes through the poria and one orbitale because these points are (skull) bony
landmarks. Sicher recommends using the mid point of the external auditory meatus as the posterior cranial landmark. Most articulators do not have
reference point for these posterior land marks lies 7mm superior to the axis and recommends composition by making anterior point of reference 7mm
below the orbitale or positioning the orbitale pointer 7mm above in the articulator to the orbitale indicator.
3. Nasion minus 23mm : Again according to Sicher another skull landmark the Nasion can be used as the anterior reference point. The nasian guide
or positioner which relates to the deepest part of the midline depression just below the level of eyebrows, as used in whip-mix and SAM quick mount
face bow is designed so that it moves in and out but not up and down from its attachments to the cross bar. The cross bar is located approximately 23mm
below the nasion. When the face bow is positioned the cross bar will at the level of the orbitale. The disadvantages of using this kind of face is that this
technique depends upon the large nasion guide the morphologic characteristics of the Nasion notch and the variance of the Nasion orbitale
measurements from 23mm in the patient.
4. Incisal edge plus anterior midpoint to articulator axis

Horizontal plane distance.

Guichet - Emphasized that a logical position of casts in the articulator would be one which would position the plane of occlusion near the mid horizontal
plane or articulator. The the mid horizontal distance to the axis condyler plane is measured, this measured distance measured onto the patients from the
existing incisal edges or planned occlusal plane and then transfer is done.

5. Alae of the Nose : The occlusal plane actually parallels the horizontal plane which was concluded by Angsbreber in review of literature that the
occlusal plane parallels the campu's line with minor variations knowing this we can transfer camper plane from the patient to the articulator by using either
right or Ala as the anterior reference point.

Importance of selection of anterior reference point

1. A planned choice of anterior reference point will allow the dentist and auxiliaries to visualize and anterior teeth and occlusion in the articulator in
the same frame of reference that would in patient i.e. as if patient standing in normal postural position with eyes looking straight ahead.
2. The act of affixing a maxillary cast with its determined hinge axis to an articulator with its axis in the condyler determinants achieves greater
importance by the use of the three points of easy reference where are constant and repeatable.

To use or not use : 9

 The value of the face bow has been the topic of considerable discussion and contraversy in prosthesis dentistry for many years. Logan considered
indispensable Craddock and Symmons considered it as futile exercise. While Stansberry described a technique of positioned records and told that use of face
bow was useless. Lazzari set forth the advantages of using a facebow.

1. It permits a more accurate use of lateral rotational points for arrangement of teeth.
2. It aids in securing anterioposterior positioning of the cast in relation to the condyles.
3. A correct horizontal plane is established. Therefore the incisor plane is also properly established.
4. It helps in vertical positioning of the cast in articulators.

• Face bow transfer is not required in following conditions.

The articulators developed not to receive face bow transfer.

• Some theories of occlusion specially the Monson's spherical theory of occlusion.

• When monoplane teeth are arranged in a occlusal balance.
• No alteration of occluding surfaces of the teeth that necessitates the changes in verticle dimension.
• No inter occlusion check reports that would be of different thickness.

But when we analyse the above said facts it is very clear that by simply stating that the articulator is not designed to accept the face bow, we cannot
forget the step of facebow transfer and incorporate the errors due to blind orientation of the casts on the articulator and we cannot have single predetermined
scheme of occlusal for all patients and we cannot use mono plane teeth for all cases in fact when we are cusped form of teeth facebow transfer becomes a
must to achieve balance in entire positions. Changes do occur in vertical dimensions in complete dentures due to processing and dimension if to be
retorations requires a facebow transfer and in case any remound is desired any change is there in occlusal records needs a facebow transfer.

Vertical dimension desired and planned on articulator require facebow transfer. When use the following figures it becomes very clear that now varied
the cuspal inclination when the casts are placed at different levels in articulators of course the changes may not be so great in positions but changes do occur.

Average mountings do not serve the diagnostic imposes in distrubances that occur to positions teeth face transfer in not only useful from prosthesis
recontractive view that also diagnostic (tool in) procedure in gnathological studies. The overall opinion to which majority of the prosthodontics agree in put
forward by the academy of denture prosthodontics favouring the use facebow and concluded that "A FACEBOW SHOULD BE USED FOR MOUNTING
THE UPPER CAST ON ANY ARTICULATOR THAT HAS A FIXED AXIS OF OPENING".
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 The correct orientation of the occlusal plane is a important step and the inclination of the plane that we develop had effect on the masticatory
performance.

Kapoor and Soman showed that the masticatory performance was influenced by the plane of orientation and Hideaki, Okene and others who further
carried out the research found that maximum clenching force was greatest when the occlusal plane parallel to the camper's plane and the force decreased
when there was 5° tilt either anterior and posterior.

Modification of face bows and different types of face bows :

1. Accuracy - Kinematic- Arbitrary - Eartype

- Fascia

Eartype - Manual lenthing eg. HANAO

` - Self centering or quick mount

eg. whip-mix, Bregstorm, SAM

Even though the Snow type FBS are mechanically simple they are in convient to

` assembly on patient

- to locate

- to adjust the FB.

On the posterior points of reference directly on the skin. Therefore in 1914 Dalbeg introduced the use of ear type of facebow where the posterior ends
were modified and may fit in the car but it was not until late 60's the ear type gained populatiry.

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 Now there are so many articulatory available that each articulator had to use with special type of FB. Then Kelseg came out with adapter which
permits one type of face bow to be used 'with different articulatory. Then there came the self centering type or quick mount type of the F.B. With a built in
gear mechanism where only one mechanism help to center the fork.

- Slidematic facebow

- Quick mount or whipmix

Bregstorm

Springbow :

Further simplication of the arbitory lead to development of spring bow which eliminate the wrencnes and screws and moving parts. It is one piece
low maintenance and lower cost.

Modifications :

Disadvantages of conventional face bow fork :

1. Heatedfork when inserted into the wax rims distorts the carefully developed contours.
2. The width is fixed and sometimes difficult to be used with larger or smaller arches.
3. When the face bow transfer is to done after the centric occlusion interocclusion record, the possibility of the rim distortion is
introduced.
4. In treating the patients (for) immediate maxillary denture the face bow transfer may be complicate by remaining natural
teeth.

Advantages of modified facebow fork :

1. Does not distort facial contours the wax rim.

2. Provides adjustability and can be used with any size ofarch.
3. Minimum or no distortion when facebow transfer is made after inter occlusal registration.
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Can be used for immediate denture treatment with the natural teeth.
 It is attached to the palatal portions of the (denture) record base. A new face bow design was introduced that further simplifies the arbitory face bow
technique.

Advantages include

1. Ease and efficiency of use

2. Steriligable parts
3. One piece low maintenance design
4. Adaptability to many articulators
5. Lower cost than other car piece types

Made up of spring steel and simply springs open and closes to various head width.

CONCLUSION

Failure to use the facebow leads to error in occlusion.

Hinge axis is a component of every masticatory movement of the mandible and therefore cannot be disregarded and this hinge axis should be
accurately captured and transferred to the articulator. So it becomes a fine representative of the patient and biologically acceptable restoration is possible.

Whatever may be controversy reasoned by in the use of facebow but it should form a integral part of one prosthodontic treatment.

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