Fox Occlusal Plane Angulation Questioned

by Clayton A. Chan, D.D.S., M.I.C.C.M.O.

If the occlusal plane is flatter relative to horizontal due to slight upward head tilt what kind of occiput to C1 axis relationship would occur?  How would that effect head movements?

I had a wonderful conversation with a doctor who had serious interest as to my method of establishing the occlusal plane using the Fox plane.  He was analyzing a case I posted on our www.occlusionconnections.com/Blog in the article/blog I posted titled, "What Angle is the Occlusal Plane Relative to Horizon".  He couldn’t quite envision the root angulation and position of my articulated mounted case.

So I decided to post the finished ceph to show the actual root position of the "actual" case.  He was worried that I had atlas/C1 restrictions in my finished case.  The patient has excellent range of motion (side bending, flexion/extension and side bending).  See the actual radiographs confirm that the patient has normalized occipital-C1 space (no restricted).  This Occiput to C-1 is well within normalized limits with an unposed angled occlusal plane as nature intended.  Remember form follows function.  Also note the root angulations, occlusal plane orientation and head postion as they relate to a level horizontal.

One cannot look at models and assume roots are out of line as they relate to an unposed horizontal level head position.  Patient is symptom free with no headaches, no neck aches and no TMD pain problems as previous.  Numerous cases have proven this.

Clinicians need to start get use to seeing what a normal occlusal plane looks like relative to a normalized head posture at horizontal level!

I know many can’t comprehend the angle of this occlusal plane mounting, since flat has been considered normal among some occlusal teachings and philosophies…..A new perspective and understanding of wha is "Physologic" is needed!

Lateral Ceph taken after final restorative was completed at optimized mandibular position.  Note occlusal plane and normalized level head position unposed at time ICAT image (raw) was taken.  Occlusal plane in the mouth is the same occlusal plane angle as articulated cast mounting above.

I know I have a reputation of not knowing anything about Occlusal Planes…what can I say….I just don’t want to reproduce pathology if I have an opportunity to bring the human body toward homeostasis - health!

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© 2008 Occlusion Connections™ All Rights Reserved
http://www.occlusionconnections.com/

Neuromuscular Dentistry

What Angle is the Occlusal Plane Relative to the Horizon?

by Clayton A. Chan, DDS, MICCMO

Nature has amazingly design the masticatory system in such a manner to meet the functional demands in a very physiologic manner.  Our occlusal, cervical, airway and postural system has been pre-determined genetically to function optimally relative to earth’s gravitational forces.  An angled or slanted occlusal plane is natures design when the head is properly supported by balanced muscles.

Because of gravity, the muscles of the structural system as well as the masticatory system allows the human being to function with the head in properly balanced manner to avoid strains and fatigue to the overall postural system. A person with a forward neck posture will accommodate to maintain the flow of oxygen into his/her body.  This forward neck and head posture tendency is indicative of an upward head tilt with a resulting flatter occlusal plane.  The upward head tilt contributes to TMD and accommodative pathologic issues (e.g., shoulder pain, neck pain, temporal headaches).  This upward head tilt is the bodies way to accommodate due a mal-aligned bite which tries to defy natures gravitational vertical forces, resulting in a flatter more leveled occlusal plane which does not represent what nature originally intended in its design.

The SN (Sella-Nasion) Plane is noted in the dental literature as a standard objective leveling reference.  What you see in the lateral ceph below is one of one of my patients, male age 47 who presented with former TMD cervical neck problems. Symptoms were resolved with an orthotic. The previous upward head tilt responded positively to the orthotic therapy allowing nature to correct it's head posture including and an improved occlusal plane.  Based on this corrected and more normalized occlusal plane orientation as seen in the below lateral cephalogram I want to transfer this occlusal plane orientation to a flat analyzing table on my articulator to fabricate the upper and lower restorations for FM rehab esthetically and anatomically.

It seems to me that if SN plane is level, symptoms are gone, and patient’s head is now balanced.  Recording this position is the most logical to communicate with the lab to mount the case.

© 2009 Clayton A. Chan, DDS.   All Rights Reserved

to record this maxillary occlusal plane orientation I use the Fox plane as indicated in the blog articles and other publications I have written. It takes the guess work away from the laboratory as long as you implement the process properly like anything. Errors can occur during the following steps:

1. During the bite registration stage.  If one use computerized mandibular scanning (jaw tracking - eg. scan 4/5 with TENS) and does not have adequate training to accurately interpret and record this kind of neuromuscular bite registration error can occur before the case is even started.
2. If the EMG interpretation is not correct and one implements erroneous EMG diagnostic protocols (unable to decipher the differences between fatigued EMG patterns vs. normalized EMG patterns or does not monitor the cervical group EMGs believing that these EMG recordings are the same as SCM  EMG recordings one will be greatly mistakened.
3. Subjective interpretation in these areas of diagnostics will also lead to failed treatment results. 

I believe in using good artistic and scientific clinical judgments to record head levelness like any diagnostic protocol, using the Modified Fox Plane technique as I have formerly indicated is a simple, inexpensive and effective tool every dentist in North America can use.  (By the way, every dental student has been issued a Fox Plane in dental school as a basic learning tool). Note the angle of the occlusal plane.
(These are real time pictures that I routinely take during my clinical work up to document what I actually observed).

© 2009 Clayton A. Chan, DDS. All Rights Reserved

Note how the maxillary recording is simply recorded at level using fast set PV on the bite fork of the Fox Plane and the transferred to a level table. This nicely correlates with the lateral ceph occlusal plane which objectively confirms the mounting and occlusal plane transfer.

© 2009 Clayton A. Chan, DDS. All Rights Reserved

The maxillary cast is simply transferred to the table via the OPI (occlusal plane index) from the Fox Plane recording.  (Read more on Mounting the Maxillary Cast Using the Fox Plane and Occlusal Plane ).

This is the actual photo that some skeptics have tried to alter to disparage the modified Fox Plane technique I have been advocating.  (Important Note: In the background the level counter and bottles sitting on top shows that my patient's head is leveled.  The bottles and level counter top are not slanting and or angled as some scrupulous "instructor/teachers" have tried to convey in their lectures by altering this image in their lectures to distort the truth of my Fox Plane recording).  Level = Level!

In a purposeful attempt to disparage and misconstrue the facts of my published article, a dentist instructor "teacher" of a "cosmetic NM teaching center" used this picture and altered and flipped it in an attempt to discredit my teachings during during his lectures.  What is amazingly wrong with his attempt is that he failed to fully read and comprehend the article that was published in the ICCMO Anthology (Chan, CA: A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture: Optimizing the Neuromuscular Trajectory – a Key to Stabilizing the Occlusal-Cervical Posture.  International College of Craniomandibular Orthopedics (ICCMO) Anthology VIII, 2007).  His biased publicized lecture subtitle shown in the below power point slide shows his unscrupulous dishonest disregard for scientific and academic teaching integrity and is in itself a "contradiction".  Additionally, it shows his lack of knowledge and understanding of basics in lateral cephalograms.

This is the altered and flipped picture by this "occlusion teachers" with the accompanying text.

Below is the unscrupulously altered photo by the same dentist (instructor "teacher" of an institute) who purposely altered  my photo again in a second power point slide (by rotating and altering the above photo) and used it without permission in a manner to give a misleading and false impression to the attending listening doctor audience about my occlusal plane teachings and understanding of how I advocate the use of the Fox Plane.  One of my dentist colleagues discovered and reported this poorly mishandled power point slide exposing this doctor/ "teacher's" credibility as an "occlusion instructor" by pointing out in the background the tipped bottles that were positioned on a counter in the background.  The unethical teacher/lecturer purposely rotated the photo to mislead, misguide and convey a false teaching about me and what I believe about head posture, the maxillary occlusal plane orientation and what I consider as horizontal level.

The lecturer/ "occlusion teacher" has exposed his credibility and lack of academic honor.  Such stupidity does not go unnoticed by those who have astute eyes to see beyond what is obvious.  Postural balance is maintained best when the head, neck, shoulders, pelvis and feet are leveled to Earth's horizontal level.  Dentists and the viewing audience clearly recognize what level is and realize that the angled human occlusal plane is simply determined when the dentist can clearly see things from a balanced perspective - not from a distorted biased and altered view). 

The unposed head posture clearly shows the natural angled occlusal plane of the same patient in this lateral cephalogram.

Lateral cephalogram (ICAT) after comprehensive restorative treatment.  Note: unposed natural head position and natural angled occlusal plane.  Images have not be altered or modified.  (You decided ...is the occlusal plane angled or flat?)

© 2009 Clayton A. Chan, DDS. All Rights Reserved

The wax up was done to match the mount using the maxillary transfer table.   Restorations were fabricated to the same mount without alterations to the mount.  (Dr. Chan proudly gives recognition for outstanding ceramic and waxing to Las Vegas Esthetics Lab, Ray Foster and Team).

© 2009 Clayton A. Chan, DDS. All Rights Reserved

I check the crown ratios (they shouldn’t look funny)…reconfirm my AP…check my patient’s subjective responses.  Many dentist and I have discover that when the correct occlusal plane is properly managed, the patient doesn't experience any neck, cervical and shoulder pain problems.  If one uses the classic HIP (hamular notch and incisive papilla) method to manage the case too completion that many are discovering that this can lead to unresolved TMJ/occlusal problems.  If everything seems to line up I go for it!

© 2009 Clayton A. Chan, DDS. All Rights Reserved

I mount my cases and check my cases from the lab to see if they maintained the correct maxillary orientation before delivery (labs are not allowed to cheat or change the mount unless it is wrong). I check my mount. I check the photos, I check and compare what is in the mouth, I check how the angle and slant is…I analyze and re-analyze and confirm with my lateral ceph, check my EMG data (making sure my patients are comfortable and stable), I check my Scan 4/5, scan 2’s, scan 8’s, etc. and decided that this orientation got to be right from the frontal and lateral views….then a re-check the patient and I re-check at the lab bench…. Seems right to me!

© 2009 Clayton A. Chan, DDS. All Rights Reserved

I am happy…that He is happy…. "Don’t lose sight of the Power of the Bite!” I have no regrets about the Fox…because I know it works for me and it works for all the talented clinicians who understand this concept. These pictures are immediately after lower seat, before any adjusting of any crowns….I had the patient come back the next day to TENS and refine the bite.
My patient is very pleased, no neck cervical TMD problems. The bite is awesome.  After gneuromuscular esthetic dentistry the patient no longer reports cervical pain, no shoulder pain, nor any TMD issues.  The patient is stable and very happy.  He is a public speaker and is on streaming internet video weekly and has a great pleasing smile.  You can view him at: http://www.iclv.com/ or spiritflow.net on Sunday mornings and Sunday evenings.

Although, there is some dental literature that tries to indicate that the occlusal plane is parallel to certain boney references as the hamular notch and incisive foramen) they often do not realize that cervical bones from C1 to C7 are not perpendicular, thus misleads and confuses the reader as to which horizontal they are refering to.  Dental literature both in the orthodontic, restorative and prosthetic arena clearly have reported on average an occlusal plane angle of 6-14 degrees when the horizontal gaze is parallel to earth's horizontal level.  Any dental referencing technique that advocates an occlusal plane horizontal to earth's horizontal plane certainly is contributing dental failure and postural/occlusal instability.

A physiologic occlusal plane, determined by balanced cervical neck, shoulder and masticatory muscles of the head is routinely angled by natures design to be perpendicular to a normalized lordotic curvature of the neck from C1 to C7.  This orientation is physiologically sound according to natures proportional design for optimal function of the pharyangeal airway (breathing), optimal head posture for physiologic functioning and positioning of the lower jaw, and proper shoulder posture.  Proper mandibular positioning relative to the cranium does effect and impact body balance, flexion, extension and rotational movements.

Dentists have ignored physiology far too long and have destroyed much with their hands, what nature has spent years growing and developing. A flat occlusal plane relative to horizontal level represents mal-alignment and dysfunction contributing to body fatigue.  Neuromuscular science supports normalize occlusal form.  If clinicians ignore what nature intends they WILL be building fatigue into their cases.  You cannot fool physiologic and anatomical science, especially when it is tested amongst thousands of great clinicians who understand the realities of conservative, ethical and thoughful judicious "gneuromuscular/neuromuscular" treatment for their patients.

As you all know I take a lot of records and this is just a small sampling of what many have been privately emailing me to show what I do. Some may not agree, but I am fine with that. My patient is extremely happy and satisfied.
The occlusal plane should look natural and balanced with the smile (that is how it should appear)…the mount is what tweaks our minds…the lateral ceph objectively confirms the reality, but it may be a need for a paradigm shift in occlusal thinking and re-evaluate whether your occlusal plane mount is too flat or not.  It's worth investigating.

Conclusion:
1) We ultimately desire the cervical neck muscles balanced, thus we observed that the head tilts downward from an upward pathologic TMD position which TMD patients present with (flatter occlusal plane relative to horizontal level), 2) we desire optimal esthetics smiles lines and our patients to be asymptomatic.  We observe on lateral cephalograms that the occlusal plane is angled – no symptoms and 3) we simply desire to reproduce what we actually see in a stable, symptom free system – angled occlusal plane, and not have our lab technicians guess or alter the mounts, thus the Fox plane method we advocate as many recognize as simple and logical is easily transfered via the Fox Plane method indicated at Occlusion Connections.

To read more: The Science of Aligning Body Parts To Improve Function - Part I

© 2009 Clayton A. Chan, DDS. All Rights Reserved.  

Neuromuscular Dentistry

Mounting the Maxillary Dental Cast Using the Fox Plane

by Clayton A. Chan, D.D.S.
USING THE FOX OCCLUSAL PLANE - 3 STEPS
The task of orienting the maxillary cast is often given to the dental laboratory technician. The clinician usually has little awareness as to how the maxillary cast is technically mounted and often assumes it is being done correctly. In reality it is commonly being manipulated to position by the lab technician in the plaster room often with no accurate record or registration to go by. It is the lab that is deciding the maxillary cast orientation and mounting position. More often than most it is not the clinician. I see this as a huge problem for those clinicians wanting to take their cases to the next level. If so they need to take control and give the lab technician an accurate reference to mount the upper cast each and every time. In order to implement this simple technique it is imperative that the cervical neck is stable, if not the leveling of the Fox Occlusal Plane will challenge the clinician. This is what I do!

To orient my maxillary dental cast correctly as it relates to the patient's head orientation at level, I simply use a Fox Plane and a flat mounting table.

Sophisticated simplicity! My lab technician loves it's simplicity and accuracy.

Step 1: I record the maxilla's orientation in the patient's mouth using Dentsply's Trubyt Fox Occlual Plane. It is very simple! With the patient's head at level (eyes looking straight ahead at the horizon), I like to have the patient standing, I use a 30 second set Polyvinyl (PV) bite registration material and inject it on the bite fork. I then place the bite fork of the Fox Plane up against the anterior teeth keeping the Fox Plane level to the ground and level to the patient's leveled head. I do not press the PV Fox Plane up against the upper posterior teeth. If you do you are screwing up the occlusal plane indexing (OPI) record for your maxillary mount. Only the anterior central teeth should penetrate the PV material on the bite fork.


From the frontal view the Fox Plane is perpendicular to the long axis of the face. (I do not reference to asymmetric eye levels, neither distorted ears levels, but rather observe the overall long-axis of the face to establish a perpendicular level frontally). From the sagittal view I use an imaginary line from the corner of the eye (exocanthion) to the connecting line of the temple of the head and base of the anterior portion of the earfold (I call it the temporal helical fold). From the sagittal view I want this line level/parallel to the ground. The Fox Plane is also leveled parallel to this imaginary line when capturing this maxillary orientation record, I call the OPI - Occlusal Plane Index. Once it is set, I check for levelness both frontally and sagittally and remove it from the patient's mouth.

Step 2: I peel the set PV index from the Fox Plane bite fork and position the OPI to the flat mounting table, positioning it flat againsT the flat table in the anterior and middle of the table. [Any flat mounting table fitted to any articulator will work. There are a number of articulator companies that offer these tables (a growing trend in articulation it seems) and any table will work. I use Ivoclar's Stratos 200 Semi-Adjustable Articulator fitted with the "Flat set up table" and "Instrument carrier" (Stock #536394 and #536399)].

Step 3: Orient the maxillary cast into the PV OPI recording your took using the Fox Plane and mount the upper cast with mounting stone. You can stablize the OPI and stone cast with hot melt glue from Home Depot. It works great! Just wet the model first and blow dry the surface dampness quickly with compressed air and mount.

Note: The natural occlusal plane slant is simply transfer from the mouth accurately via the Occlusal Plane Index (OPI) record with fast set PV bite registration. (Read more to see the corresponding lateral cephalogram on "What Angle is the Occlusal Plane to the Horizon?) The maxillary cast mount is not accurately duplicated.

Now you have the maxillary cast mounted to level just as it was in the patient's mouth, with patient's head at a level position. Pretty simple! Anybody can do it! Most of you dentist all have a Fox Plane from dental school! Pull them out and use them. Your Lab Technicians will love you for this.

If you don't want to mount the upper cast yourself, then simply remove the PV OPI record from the Fox Occlusal Plane and mail it to your technician of choice. There are no moving parts to distort, more or shift during transportation or shipping to the lab. Make sure you send a frontal view photo of your patient so your lab can confirm the mounting visually.
For those clinicians not familiar with a proper head position and occlusal plant slant, what would appear as not natural may in actuality be physiologic once one learns what a proper head position is and how the position of the mandible effects head positioning and head tilt. Controlled studies have shown a normal "physiologic" occlusal slant is 6-14 degrees and not flat as many believe. Remember: If you are having difficulty in keeping the head level while recording the occlusal plane via this Fox Plane technique perhaps you may want to reconsider whether your patient's cervical neck posture is truly stable. An unbalanced cervical aligment will effect occlusal/mandibular stability.
If you would like to read more on the rationale, science and reasons why I choose to mount my complex cases in this simple way you can read my article "A Clinical Significance of the Occlusal Plane".