142 The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3

Relationship of anatomic landmarks

with occlusal plane
Rubina Gupta, Himanshu Aeran, S. P. Singh
ABSTRACT
Purpose: Evaluat ion of relat ionship bet ween various anat omical landmarks and t he occlusal plane in t he nat ural dent it ion
t hat could be used for est ablishing t he occlusal plane in complet e dent ures. Met hods: The st udy comprised of 1 0 0 dent ulous
subject s wit h all healt hy permanent t eet h in normal arch form and alignment . Three inst rument s were cust om-made for t he
purpose: t he occlusal plane analyzer t o check t he parallelism of t he ala-t ragus lines, and t he int erpupillary line, t he buccinat or
groove relat or and t he level analyzer for t he level of t he linea alba buccalis wit h t he occlusal plane. For t he ret romolar pad area
a met allic scale was used. Result s: Wit hin limit at ions of t his st udy, it was observed t hat , only 1 3 % subject s showed occlusal
plane parallel t o t he int erpupillary line. The post erior reference point of Camper s line was middle point for 7 2 % of males and
superior point for 8 0 % of females. Int raorally, 6 8 % of subject s have t he occlusal plane at t he same level as t hat of buccinat or
groove and 7 7 % of t he subject s had t he occlusal plane at t he middle one-t hird of ret romolar pad area. Int erpret at ion and
Conclusions: It was concluded t hat : t he occlusal plane is parallel t o Camper s plane post erior reference point as t he superior
point of t ragus in females and middle point in males. The occlusal plane is not generally parallel t o t he int erpupillary line.
Int ra-orally, t he level of buccinat or groove is reliable, while variat ions in ret romolar pad area make it an unreliable landmark
for orient ing t he occlusal plane.
KEY WORDS: Buccinat or groove, camper s line, occlusal plane, int erpupillary line, ret romolar pad area
DOI: 10.4103/0972-4052.57083
Ori gi nal Arti cl e
D epar t ment o f Pro st ho d o nt i cs, Subhar t i D ent al Co l l ege, M eer ut , I nd i a
A d d r ess fo r co r r espo nd ence: D r. Rubi na Gupt a, C/ O D r. S. K. Gupt a, A mbeka Eye & Laser H o spi t al , 2 0 3 / 4 8 , Sad ar Baz aar, M uz affar nagar - 2 5 1 0 0 1 ,
U . P, I nd i a. E- mai l : d r _ r ubi nagupt a@ yaho o . co m
INTRODUCTION
The desire t o look good and feel healt hy is not limit ed
by age. Since time immemorial, dentists have faced the
challenge of providing accord bet ween funct ion and
est het ics. The occlusal plane, lost in pat ient s rendered
edent ulous, should be relocat ed if complet e dent ures
are t o be est het ically and funct ionally sat isfact ory.
GPT (July 2005)
[1]
defines occlusal plane as the average
plane est ablished by t he incisal and occlusal surfaces
of t he t eet h. Generally it is not a plane but represent s
t he planar mean of t he curvat ure of t hese surfaces.
Funct ionally, t he inclinat ion of t he occlusal plane is
one of t he key fact ors governing occlusal balance and
phonat ion. Est het ically, t he ant erior occlusal plane
t akes on a fundament al role.
Con s i d e r i n g t h e i mp or t a n c e of t h e a c c u r a t e
establishment of the location and inclination of occlusal
plane on funct ion, est het ics and speech, a met hod t o
conform it t o t he occlusal plane t hat exist ed in t he
nat ural t eet h seems necessary. Various aut hors have
advocat ed different met hods for t he orient at ion of
t he occlusal plane. Most import ant and accurat e of
t hese is pre-ext ract ion record, eg: profile phot ographs,
lead wire, acrylic face mas k, dent ulous cas t s et c.
Unfortunately, these records are generally not available.
Numerous aut hors, since t he beginning of complet e
dent ure fabricat ion, have proposed several landmarks
to help define the level of occlusal plane. Various planes
like Frankfurt horizont al plane, Campers line, Palat al
line, Occlus al line, Mandibular line, Int erpupillary
line, Hamular not ch incisive papilla (H.I.P. plane) et c.
have been suggest ed. Many int raoral landmarks like
commissures of t he mout h by Gillis
[2]
in 1933, Incisive
papilla by Robert N. Harper
[3]
in 1948, parot id papilla
The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3 143
Gupta, et al.: Anatomic landmarks with Occlusal Plane
by P. F. Foley and G. H. Lat t a
[4]
in 1985, upper lip line by
Rahn and Heart well
[5]
in 1986, height of t he ret romolar
pad, t he lat eral borders of t he t ongue et c. have also
been suggest ed
In 1979, H. Oka ne
[6]
found t ha t during clenching
maximum biting force was greatest and muscle activity
was least when t he occlusal plane was made parallel
t o t he ala-t ragus line. Landa
[2]
in 1947 said t hat t he
occlusal plane is parallel t o line drawn from t he alae
of nose t o t he middle point of t he t ragus while Art hur
O. Rahn and Charles M. Heart well (1986)
[7]
said t he
occlus al plane s hould coincide wit h Campers line
(superior border of t he t ragus). On t he ot her hand,
F. Rost amkhani, A. Sahafian and H. Kermani (2005)
[8]

conduct ed a cephalomet ric st udy and concluded t hat
t he inferior border of t he t ragus can be suggest ed
as t he post erior point for ala-t ragus line orient at ion.
Various aut hors like J . E. Scot t (1952)
[9]
described an
inst rument t he bit e plane leveler, Nikzad S. J avid
(1974)
[10]
suggest ed t he use of J -plane, Kazanoglu
& J ohn W. Unger (1992)
[11]
described Campers plane
indicat or

and Urbano, Sant ana-Penin & Maria J . Mora
(1998)
[12]
described a U-shaped device for analyzing the
level of ala-t ragus line. In 1993, Vincent Kokich
[13]
said
for good esthetics the occlusal plane should be parallel
t o int erpupillary plane while J eff Morley and J immy
Eubank (2001)
[14]
said t he creat ion of an incisal plane
perpendicular t o t he facial midline produces a reliable
and repeat able posit ion t hat does not depend on t he
int erpupillary line.
J ack Piermat t i (2006)
[15]
said t he occlusal plane should
terminate at the upper level of the retromolar pad while
Art hur O. Rahn and Charles M. Heart well (1986)
[7]
said
post erior height should not exceed half t he height of
t he ret romolar pad. On t he ot her hand, K. Shigli, B.R.
Chetal and J. Jabade (2005)
[16]
found the lower one-third
of t he ret romolar pad consist ent wit h t he mandibular
occlusal plane while Robert L. Engelmeier (1996)
[17]
said
in the sagittal view the occlusal plane is determined by
t he incisal edges of maxillary cent ral incisors and t he
approximat e junct ure of t he upper and middle t hirds
of t he ret romolar pad.
K. Shigli, B.R. Chet al and J . J abade (2005)
[16]
found t hat
t he mean value of all readings of buccinat or groove
was 0.94 mm below t he mandibular occlusal plane
and is a reliable int raoral landmark for occlusal plane
det erminat ion.
It is evident t hat t he various concept s report ed in
lit erat ure allow variat ion in t he locat ion of occlusal
plane. Hence a need was felt to evaluate the relationship
bet ween t he occlusal plane, ext raoral and int raoral
landmarks.
Aims and Objectives
To assess relationships between intraoral and, extraoral
s oft t is s ue la ndma rks , Viz . Ret roret romola r pa d,
buccinat or groove, ala-t ragus line and int erpupillary
line, wit h occlusal plane
To determine consistency of soft tissue landmarks with
occlusal plane in both sexes and check for any variation
To evaluat e t he significance of soft t issue landmarks
in est ablishing lost occlusal plane
MATERIAL AND METHODS
Selection Criteria
The st udy was conduct ed on 100 dent ulous subject s
(50 males and 50 females)
Age group = 17 21 yrs
No hist ory of
ort hodont ic t reat ment
facial t rauma or surgery causing asymmet ry of t he
eyes
no gingival or periodont al condit ions or t herapy
t hat would undermine a healt hy t oot h-t o-t is s ue
relat ionship.
All healthy permanent teeth were present in normal
arch form and alignment wit h
no int erdent al spacing or crowding present .
t eet h were not grossly abraded or at t rit ed
no gross dent al rest orat ions t hat might alt er t he
plane
no e vid e nce of g ing iva l a lt e ra t ion or d e nt a l
irregularit ies
Abs ence of a ny a ppa rent defect , deformit y or
asymmet ry of t he face
Instruments Used
1. Occlusal Plane Analyzer [Figure 1]
This ins t r ume nt wa s cus t om ma de t o che ck for
parallelism of ala-t ragus line t o t he occlusal plane and
occlusal plane t o int erpupillary line.
A FOX PLANE (Dr. Frank Fox (Dent sply / York division,
York, PA) was t aken. Four long screws were at t ached
at t he four ends of occlusal plane relat or arm, care was
t aken t o place t hese screws parallel t o each ot her.
Three met al plat es (t wo in oblique direct ion and one
in horizontal) were then attached to these screws. Two
plat es (oblique) were made parallel t o t he occlusal
plane relat or arm. It served t o analyze t he parallelism
of occlusal plane wit h ala-t ragus line. The t hird plat e
(horizont al) was parallel t o t he front al connect ing arm
which could relat e t he occlusal plane t o int erpupillary
line. A mark was made on bot h t he sides of all t he
plat es . The corres ponding mark, which was in a
straight line to the mark on the plate, was placed on the
144 The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3
arms of t he fox plane. These marks helped det ermine
parallelism of t he plat es by measuring t he dist ance
bet ween t he plat es.
A met al key was also provided wit h t he inst rument
t o open t he met al collars and help move t he plat es up
and down.
2. Digital Vernier Callipers:
Digit al Vernier calipers, wit h an accuracy of .001mm,
were used t o check t he dist ance bet ween t he t wo
arrowheads on t wo parallel plat es.
3. Buccinator Groove Relator: [Figure 2]
It wa s cus t om ma de t o compa re t he level of t he
buccina t or groove (linea a lba bucca lis ) wit h t he
occlus a l pla ne. A ver t ica l impres s ion pla t e wit h
rounded ends was at t ached on eit her side of t he bit e
fork. The ends of t hese plat es were rounded t o avoid
any possible injury to the soft tissues. Small holes were
made on t he vert ical plat es t o help for t he ret ent ion of
t he impression mat erial.
4. Level Analyzer: [Figure 3]
An ushaped plat e was made t o check t he level of
buccinat or groove wit h t he occlus al plane on t he
impression t aken. While fabricat ing, care was t aken t o
make sure bot h t he prongs of t he U were at t he same
level and parallel t o each ot her.
5. Metallic Scale:
A t hin 6 st ainless st eel scale was used t o relat e t he
occlusal plane t o t he ret romolar pad.
Procedure
STEP - 1: Parallelism of Occlusal Plane t o Campers Line:
Subject s are seat ed in an upright posit ion on a dent al
chair so t hat t hey looked forward at t he horizon. Using
a surgical marking pencil, t hree point s are marked
on t he t ragus of t he subject according t o it s locat ion
i.e. superior, middle and inferior. The occlusal plane
analyzer is placed in t he subject s mout h and held in
position by the subject biting over it. The plate is raised
unt il it coincided wit h ala of t he nose. [Figure 4]
The dis t ance bet ween t he arrowheads on t he t wo
plat es is t hen meas ured us ing t he digit al vernier
calipers. Same dist ance bet ween t he t wo plat es on
bot h sides indicat ed parallel opening. [Figure 5]
The post erior end is t hen checkedwhet her t o see if it
coincided wit h t he superior, middle or inferior point of
t he t ragus. The procedure was repeat ed for bot h t he
sides.
STEP 2: Parallelism of Occlusal Plane to Interpupillary Line:
The parallelism of occlusal plane wit h int erpupillary
line is checked using t he same inst rument . Wit h t he
subject seat ed in t he upright posit ion, t he occlusal
plane analyzer is placed in t he subject s mout h and
held in position by the subject biting over it. The frontal
met al plat e is t hen made parallel t o t he int erpupillary
line. Finally, t he parallelism is checked wit h t he front al
connect ing arm of t he fox plane, by measuring t he
dist ance bet ween t he t wo plat es using digit al vernier
ca lipers . Sa me dis t a nce bet ween bot h t he ends
indicat ed parallelism. [Figure 5]
STEP 3: Level of Occlusal Plane with Linea Alba Buccalis
For t he buccinat or groove, t he buccinat or groove
relat or and level analyzer are used. An irreversible
hydrocolloid impression mat erial (alginat e Zelgan
2002.Dent s ply) is us ed t o make t he impres s ion of
t he buccinat or groove. An indelible pencil is used t o
mark t he groove in t he subject s mout h [Figure 6].
For t he impression, alginat e mat erial is placed on t he
vert ical impression plat es. It is made cert ain t hat t he
dist al aspect s of t he buccal vest ibules on bot h sides
are filled. The subject is t hen asked t o pucker his/ her
lips as in sucking wit h t he lips slight ly separat ed, but
wit hout t he loss of cont act of t eet h wit h t he bit e plat e.
This helps t ransfer t he mark t o t he impression. The
impression is t hen removed from t he mout h, washed
wit h wat er and excess t rimmed.
The level analyzer is t hen used t o check for t he level of
t he groove in relat ion t o t he occlusal plane. One of t he
prongs of t he plat e is kept on t he t op side of t he bit e
plate (depicting maxillary occlusal plane) such that the
second prong ext ends on t he ot her side of t he vert ical
plat e, carrying t he vest ibular impression [Figure 7].
The coincidence/ non-coincidence of t he groove t o
t he occlusal plane is t hen not ed. Similar procedure is
followed for t he ot her side also.
STEP 4: Relationship of Occular Plane with Retromolar Pad
Using a surgical marking pencil, t he ret romolar pad
area of t he subject is divided int o t hree equal zones.
The st ainless st eel scale is t hen slided post eriorly over
t he cusps of t he mandibular post erior t eet h ensuring
it s cont act wit h t he t ip of t he cuspid on one side of t he
mandibular arch t o make cont act wit h t he ret romolar
pad. The zone of cont act i.e. t he superior one-t hird,
middle one-t hird or t he junct ion of superior or middle
one-third of the retromolar pad, is then recorded [Figure
8]. The process is repeated on the other side of the arch.
St at is t ical analys is was carried out us ing: CHI
SQUARE TEST. The level of significance adopt ed was
5%.
RESULTS
Gupta, et al.: Anatomic landmarks with Occlusal Plane
The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3 145
Figure 1: Occlusal plane analyzer Figure 2: Buccinator groove relator
Figure 3: Level Analyzer Figure 4: Parallelism of Occlusal Plane to Campers Line
Figure 5: Checking Difference with Digital Vernier Calipers Figure 6: Level of Occlusal Plane with Linea Alba Buccalis
Gupta, et al.: Anatomic landmarks with Occlusal Plane
Figure 7: Checking level of Linea Alba Buccalis using Level analyzer Figure 8: Relationship of occlusal plane with retromolar pad
146 The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3
Occlusal Plane and Campers Line
The occlus al plane analyzer was us ed [Table 1]; a
variation of posterior reference point of Campers line in
males and females was also observed. It was seen that
72% of males had middle point as post erior reference
point while 80% of females had superior point as t he
post erior reference point showing parallelism t o t he
occlusal plane
Occlusal Plane and Interpupilalry Line
The same inst rument was used t o analyze parallelism
of t he occlus al plane wit h t he int erpupillary line.
Des pit e various claims only 13% s ubject s s howed
occlusal plane parallel t o t he int erpupillary line. Not
much difference was observed bet ween t he t wo sexes
[Table 2], 92% of males and 82% of females showed
cant ing
Occlusal Plane and Buccinator Groove
The buccinat or groove relat or was used t o relat e t he
occlusal plane wit h t he level of buccinat or groove. The
level analyzer was used to analyze the level; 70% males
and 66% females have t he groove at t he same level of
t he occlusal plane. So t he buccinat or groove can be
used as a reliable [Table 3] landmark for orient at ion of
occlusal plane.
Occlusal Plane and Retromolar Pad
A met allic scale was passed along t he cusp t ip from
cus pid t o mandibular II / III molar and ext ended
pos t eriorly t o check for t he relat ions hip bet ween
occlus a l pla ne a nd ret romola r pa d. Ins ignifica nt
diffe re nce be t we e n t he ma le s a nd fe ma le s wa s
observed as 76% of males and 78% of females wit h
occlusal plane at t he level of t he middle t hird of t he
ret romolar pad area [Table 4].
Comparing the right and lef side
Variat ion of occlusal plane relat ionship wit h t he ala-
t ragus plane, buccinat or groove and ret romolar pad
area was obs erved on t he right and left s ide. The
ret romolar pad area s howed maximum number of
variat ions followed by buccinat or groove; leas t in
relat ing t he ala-t ragus line t o occlus al plane. This
indicat es t hat ala-t ragus plane is a reliable [Table 5]
landmark for orient ing t he occlusal plane. Int raorally,
buccinat or groove is t he best available landmark.
DISCUSSION
The orient at ion of t he occlusal plane lost in pat ient s
rendered edent ulous should be relocat ed if complet e
dent ures are t o be est het ic and funct ion sat isfact orily.
The orientation of the occlusal plane forms the basis for
t eet h arrangement conducive t o sat isfact ory est het ics
and proper funct ion.
Table 1: Parallelism of occlusal plane with campers line
Campers Line Males Females Total
(Ala of T=the nose to) (%) (%) (%)
Superior point of tragus 24 80 52
Middle point of tragus 72 20 46
Inferior point of tragus 4 0 2
Table 2: Parallelism of occlusal plane with
Inter-pupillary line
Inter-Pupillary Line Males Females Total
(%) (%) (%)
Parallel to occlusal plane 8 18 13
Not parallel to occlusal plane 92 82 87
Table 3: Relationship between level of buccinator groove
and occlusal plane
Buccinator groove Males Females Total
(At the level) (%) (%) (%)
same as that of the occlusal plane 70 66 68
Superior to the occlusal plane 30 32 31
Inferior to the occlusal plane 0 2 1
Table 4: Relationship between occlusal plane and
retromolar pad area
Retro-molar pad Males Females Total
(Occlusal plane at the level of) (%) (%) (%)
Superior 1/3
rd
8 8 8
Middle 1/3
rd
76 78 77
Junction of superior and middle 1/3
rd
16 14 15
Table 5: Variation of occlusal plane relationship with
ala-tragus plane, buccinator groove and retromolar pad
area as observed on right and left side
Males Females Total
(%) (%) (%)
Campers line 20 28 24
Buccinator groove 32 26 29
Retromolar pad 30 38 34
Gupta, et al.: Anatomic landmarks with Occlusal Plane
Ant eriorly, occlusal plane mainly helps in achieving
es t het ics and phonet ics while pos t eriorly, it forms
a milling s ur fa ce . Thus , incor re ct re cord of t he
occlusal plane would hamper est het ics, phonet ics,
and mast icat ion. It may also affect t he st abilit y of a
complet e dent ure and ult imat ely res ult in alveolar
bone resorpt ion.
Funct ionally, inclinat ion of t he occlusal plane is one of
t he key fact ors governing occlusal balance. Movement
of t he mout h during chewing shows a harmonious
relat ions hip bet ween t he t ongue, t he mandibular
post erior t eet h, and t he buccinat or muscle; incorrect
locat ion of occlusal plane, result s in malfunct ions.
Thus it can be said t hat for t he success of complet e
denture prosthesis, arranging the teeth in correct plane
The Jour nal of Indian Prosthodontic Society / July 2009 / Vol 9 / Issue 3 147
of occlusion is pivotal. Changes in the plane of occlusion
modify t he physical and funct ional relat ionship of t he
oral musculat ure leading t o an alt erat ion in funct ion,
comfor t and als o t he es t het ic value. Cons idering
t he impor t a nce of t he a ccura t e es t a blis hment of
t he locat ion and t he effect of t he inclinat ion of t he
est ablished occlusal plane on funct ion, est het ics and
speech, a met hod t o conform it t o t he occlusal plane
t hat exis t ed in t he nat ural t eet h s eems neces s ary.
Hence, t his s t udy was conduct ed t o examine t he
significance of various soft tissue landmarks as a guide
t o est ablish t he original occlusal plane as was present
in t he pat ient s nat ural dent it ion and det ermine t he
consist ency of soft t issue landmarks wit h t he occlusal
plane in bot h sexes and check for any variat ion.
SUMMARY AND CONCLUSIONS
On t he basis of t he result s obt ained, t he following
conclusions can be drawn:
In maximum number of subject s, t he occlusal plane
was found parallel t o Campers plane wit h t he ant erior
reference point as t he ala of t he nose and post erior
reference point as t he superior point of t ragus.
The pos t erior reference point of Ca mpers pla ne
showing parallelism with occlusal plane varies in males
and females. In males, it is t he middle point of t ragus
and in females t he superior point of t ragus.
The occlus a l pla ne is not a lwa ys pa ra llel t o t he
int erpupillary line. Slight cant ing was observed.
The buccinat or groove is found t o be at t he level of t he
occlusal plane in most of t he subject s; independent of
sex of the subject. Hence, it can be considered the most
st able int ra-oral landmark for orient ing t he occlusal
plane.
Majorit y of t he subject s showed t he occlusal plane at
t he level of middle t hird of t he ret romolar pad area.
However, due t o high percent age of variat ion bet ween
the right and left side it cannot be considered a reliable
landmark for orient ing t he occlusal plane.
The results of this study indicate that no single method
wa s a ccura t e in det ermining t he occlus a l pla ne.
However, using more t han one of t hese paramet ers
along wit h a judicious clinical judgment , we can
be very close t o t he ideal occlusal plane level for an
edent ulous pat ient .
It must be const ant ly borne in mind t hat t he occlusal
plane is det ermined by t he dynamics of funct ion and
not by any part icular s t at ic relat ions hip. It is als o
advisable that occlusal plane should be selected on the
basis of anat omical landmarks, est het ics, phonat ion,
comfort and funct ion.
ACKNOWLEDGMENT
We place on record our grat it ude t o Dr. (Maj. Gen) V. K.
Sood and Dr. Sanjay Yadav.
Gupta, et al.: Anatomic landmarks with Occlusal Plane
Source of Support: Nil, Conict of Interest: None declared.
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