DOI: 10.7860/JCDR/2015/11820.

5575
Original Article

Relationship Between Occlusal Plane and

Dentistry Section

Three Levels of Ala Tragus line in Dentulous

and Partially Dentulous Patients in Different
Age Groups: A Pilot Study
Saquib Ahmed Shaikh1, Lekha K.2, Gaurav Mathur3

ABSTRACT ala of nose were marked on photographs. These were joined to

Statement of problem: Correct orientation of the occlusal plane get three different levels of Ala-Tragus line. Images were analysed
plays a vital role in achieving optimal aesthetics, occlusal balance photometrically and most parallel relationship was determined in
and function of complete dentures. The use of ala tragus line for between arms of fox plane (that represented the occlusal plane)
determination of occlusal plane has been a topic of debate over and three different levels of ala tragus line. Data obtained was
past many years. Also, the effect of age on level of ala tragal line subjected to statistical analysis using Pearson chi-square and
has not been investigated in the past. Likelihood-ratio chi-square test.
Purpose: To determine the effect of age on location of Ala-Tragus Results: Significant correlation was found between age and
line. level of Ala-Tragus line. The occlusal plane was found to be
more parallel to Ala-tragus line when inferior border of tragus
Materials and Methods: A total of 180 patients (90 males
was considered as posterior reference point in young adult age
and 90 females) were selected with complete dentition and
group (20-35 y). In older age groups, occlusal plane was found
were grouped according to their age in three age groups with
to be more parallel to Ala-tragus line when middle of tragus was
60 subjects in each age group (Group A: 20-35 y, Group B: 36-
considered as posterior reference point.
50 y, Group C: 51-65 y). Right lateral profile photographs were
taken with subjects having fox plane placed intraorally parallel Conclusion: Within the limitations of this study, it can be
to occlusal plane. Reference points corresponding to inferior concluded that a definite relationship exists in between age and
border, middle or superior border of tragus and inferior border of level of ala tragus line.

Keywords: Campers plane, Complete denture, Occlusion

Introduction The occlusal plane is normally established anteriorly according

Complete denture construction is a product of biological sciences to aesthetics of patient and posteriorly parallel to camper’s plane
as well as sound mechanical principles. Construction of a prosthesis [3]. GPT-8 defines campers plane as “a plane passing from the
that is in harmony with patient’s stomatognathic system is the acanthion to the center of each bony external auditory meatus;
ultimate aim of prosthetic dentistry. Full denture prosthesis places called also acanthion-external auditory meatus plane” [2].
numerous factors which are associated with prosthesis and are The use of ala tragus line for determination of occlusal plane has
in the control of operator. Though the operator is free of factors been a topic of debate over past many years. This is because various
associated with natural teeth such as mobility, caries, tooth position researchers cannot come to a consensus as to which tragal reference
etc. but he faces a new complex problem of designing prosthesis should be used for formation of ala tragal line. Also, the effect of age
in harmony with tissues which can provide an accord in between on level of ala tragal line has not been investigated in the past. This
function and aesthetics [1]. study evaluates the null hypothesis (n0) that no correlation exists
The glossary of prosthodontic terms-8 defines occlusal plane as between different age groups and the level of ala tragus line.
“the average plane established by the incisal and occlusal surfaces
of the teeth. Generally, it is not a plane but represents the planar Materials and Methods
mean of the curvature of these surfaces” [2]. This cross-sectional study was carried over a period of six months
Correct orientation of the occlusal plane plays a vital role in achieving on patients who reported in OPD of Prosthodontics Department
optimal aesthetics, occlusal balance and function of complete in SDM College of dental sciences and hospital, Dharwad, India.
dentures. Faulty orientation of occlusal plane in fixed or removable A total of 180 patients (90 males and 90 females) were selected
prostheses will affect the interaction between tongue and buccinator with complete dentition and were grouped according to their age in
muscle resulting in food collection in sulcus and cheek or tongue three age groups with 60 subjects in each age group. Any patients
biting [3]. Not only this, it can also lead to instability of dentures, who were indicated for dental restorative treatment were included
tissue alteration and untimely bone resorption. Correct orientation in this study provided that they did not have any of the conditions
of occlusal plane plays a vital role in optimal functional and aesthetic mentioned in the exclusion criteria. Exclusion criteria followed
achievement [4]. When located correctly, occlusal plane will contribute were:
a proper sense of balance in dental composition. Determination of 1. Previous history of orthodontic or orthognathic treatment
correct occlusal plane poses a challenge to operator and if not done 2. No posterior teeth present to aid in determining occlusal plane
correctly can lead to aesthetically and functionally unacceptable 3. History of facial or temporomandibular joint surgeries
dentures.

Journal of Clinical and Diagnostic Research. 2015 Feb, Vol-9(2): ZC39-ZC42 39

 Saquib Ahmed Shaikh et al., Occlusal Plane and Three Levels of Ala Tragus Line in Dentulous and Partially Dentulous Patients www.jcdr.net

4. Poor systemic health • The inferior margin of tragus (c)

5. Presence of bone or skin diseases • Inferior border of ala of nose (d)
• Line joining superior margin of tragus to inferior border of ala of
6. Congenitally missing teeth or extracted teeth
nose (ad)
7. Supraeruption or drifting of teeth • Line joining middle margin of tragus to inferior border of ala of
8. Presence of advanced periodontal diseases. nose (bd)
Age groups selected were: • Line joining inferior margin of tragus to inferior border of ala of
nose (cd)
• Group A: 20-35 y
• Line corresponding to arms of fox plane representing occlusal
• Group B: 36-50 y plane.
• Group C: 51-65 y These images were analysed using computer software Autocad
In this study, a Sony digital camera model no DSC W830 with a 2009 and most parallel relationship was determined in between
resolution of 20.1 mega pixels was used which is adequate for arms of fox plane (that represented occlusal plane) and three
computer analysis. Fox plane was placed intraorally so that it touched different levels of ala tragus line (ad, bd, cd).
incisal edges of upper incisors and cusps of left and right upper first Data thus obtained was subjected to statistical analysis using
molars. This plane thus corresponded to the orientation plane used Pearson chi-square and Likelihood-ratio chi-square test.
for construction of complete dentures. The subjects were asked
to hold fox plane in this position. Right lateral profile photographs Results
were taken with subjects sitting in natural head position with their [Table/Fig-3] shows the distribution of participants according to the
back straight. Using an adjustable tripod, the height of camera was parallelism of their Ala tragus line to occlusal plane among different
adjusted according to the patient and photographs were taken age groups. It can be seen from the table that as age advances,
from a fixed distance of one metre from patients mid sagittal plane. occlusal plane shifts more superiorly. The occlusal plane is more
Following landmarks were marked on photographs in computer parallel to line CD i.e. lower border of tragus to inferior border of ala
shown in [Table/Fig-1,2]. of nose in young adult age group (20-35 y).
20-35 y 36-50y 51-65 y
Occlusal plane parallel to Line AD 10 15 20
Occlusal plane parallel to Line BD 11 35 30
Occlusal plane parallel to Line CD 39 10 10
[Table/Fig-3]: Distribution of participants according to the parallelism of their Ala
tragus line to occlusal plane

[Table/Fig-4] shows the p-value between the participants according

to the parallelism of their Ala tragus line. It shows that there was
no statistically significant difference between the number of
participants having their occlusal plane parallel to line AD or line
BD. But marked statistical significance (p=0.001) was observed
between the participants with occlusal plane parallel to line BD and
line CD and participants with occlusal plane parallel to line AD and
line CD indicating relative constancy in orientation of occlusal plane
as individual reaches middle age.
p-value
[Table/Fig-1]: Various landmarks marked on the photograph. a-superior margin
AD-BD 0.399
of the tragus ; b-middle margin of tragus; c- inferior margin of tragus; d- Inferior
border of ala of nose AD-CD 0.001
BD-CD 0.001
[Table/Fig-4]: Comparison of parallelism of different Ala tragal lines to occlusal plane

[Table/Fig-5] shows the p value between participants based on

their age group. It can be seen that there was a marked statistical
difference between parallelism of occlusal plane to ala tragal line
in the individuals in age Group A and individuals in the age Group
B and C. But no statistical difference was observed between
individuals in the age Group of B and C. This finding further
reinforces previous observations. Therefore null hypotheses (n0)
can be rejected.
p value
Group A and Group B 0.001
Group A and Group C 0.001
Group B and Group C 0.882
[Table/Fig-5]: Comparison of parallelism of occlusal plane and Ala tragal line
among different age groups
[Table/Fig-2]: Different levels of Ala-tragus plane

Discussion
• The superior margin of the tragus (a) Relocation of occlusal plane in patients who has been rendered
• The middle margin of tragus (b) edentulous poses a challenge to clinician. It is more plausible to
relate occlusal plane to maxillary plane during occlusal reconstruction
40 Journal of Clinical and Diagnostic Research. 2015 Feb, Vol-9(2): ZC39-ZC42
www.jcdr.net Saquib Ahmed Shaikh et al., Occlusal Plane and Three Levels of Ala Tragus Line in Dentulous and Partially Dentulous Patients

rather than mandibular plane because of independence of maxillary posterior reference point. The results obtained for group B and C
plane to dentoalveolar structures and its fixed orientation to various are in accordance with some of the previous studies [7]. However,
craniofacial planes. However this is not the case with mandibular results of present study are contradicted by few researchers who
plane because of mobile nature of mandible which changes the advocated use of superior border of tragus as posterior reference
orientation of mandibular plane to craniofacial planes [5]. Also, the point [7,9,12-14]. It was also found that sex had no significant
occlusal plane should be relocated in a position in which it had influence on location of occlusal plane.
been situated previously [6]. This statement seems quite correct as For maximum occlusal stability, occlusal plane should be oriented
stomatognathic system functions normally at this position and will such that it is perpendicular to direction of occlusal forces. It has
continue functioning normally till it is altered. To aid in rehabilitation been well proven that in cases of excessive resorption, plane
of occlusal plane numerous reference planes and landmarks should be parallel and closer to lower edentulous ridge to decrease
have been suggested. Out of these, Campers planes is the most possible leverage. And this also has been shown that when occlusal
commonly used reference plane [3]. plane is developed considering lower border of tragus as posterior
However, use of ala-tragus line has been a topic of debate reference point, occlusal plane is more parallel to lower ridge and
since past many years. Several clinical investigations have been is perpendicular to occlusal forces [3]. However, the occlusal plane
conducted but still researchers cannot come to a consensus as should not be located near to mandibular ridge posteriorly for sake
to which part of tragus should be used for construction of occlusal of attaining more mechanical stability. This places occlusal plane
plane in edentulous patients. Some authors suggest use of superior in a more adverse position relative to surrounding musculature
border of tragus as reference point whereas some authors suggest and will hamper not only the function of the tongue but will also
use of middle or inferior point of tragus for this line [7,8]. Therefore, be harmful to functioning of entire stomatognathic system [15].
it’s quite evident that significant controversy exists in this matter. It will result in a compromise with both phonetics and aesthetics
Till now, literature does not support age as an influencing factor and will cause frequent tongue biting. Success of prosthesis is a
on location of ala tragus line. Hence, aim of present study was to combination of mechanical principles and harmony in between
determine effect of age on location of ala tragus line. different components of stomatognathic system. Either one cannot
To analyse level of ala-tragus line, various instruments have been be neglected at expense of other.
devised and used. Bite plane leveler, J plane, Campers plane When occlusal plane is established such that it is high posteriorly, it
indicator, and more recently, occlusal plane analyser and occlusal follows the curvature of ramus and enables teeth to be set in such a
plane orientor have been used to locate ala tragus line [4,9]. Fox way that there are least interferences during protrusive movements.
plane is the simplest and most widely used instrument to aid in These interferences if ignored can significantly decrease stability of
determining occlusal plane. But its use is error prone and is dentures. It must be constantly kept in mind that occlusal plane
associated with inter examiner variability. Also there are chances of is determined by dynamics of function and not by any particular
parallax error [4]. However, it’s use is very rapid and simple. It is less static relationship [16]. This location of occlusal plane allows normal
bulky than other instruments and is more suitable for photographic functioning of tongue, buccinator and other associated muscles
purposes. The chances of parallax error are reduced when images and will add to aesthetic outcome of prosthesis.
are subjected to photometric analysis. Also, it is the most commonly
used instrument for establishing occlusal plane in edentulous Conclusion
patients. Therefore, fox plane was used for the present study. Within the limitations of this study, it can be concluded that a
A study was conducted in which age group estimation was done definite relationship exists in between age groups and level of ala
using face angle. They estimated and classified human age groups tragus line. In young adult age group, occlusal plane is found to
according to facial features extracted from human facial digitized be more parallel to Ala-Tragus line when inferior border of tragus
images [10,11]. Facial features and various other parameters were is considered as posterior reference point and hence should be
assessed on these images in detail and age groups were classified. used as a posterior reference point in establishing occlusal plane in
These groups were. completely edentulous patients in young age group. In middle age
and old age group, both middle and superior border of tragus can
• Child: till 17 y
be taken as posterior reference point while orienting the occlusal
• Young age: 18-25 y
plane for these age groups. However, further research has to be
• Young adult age: 20-35 y
conducted to determine exact cause and relationship between
• Mid age: 36-50 y
age and level of occlusal plane. Also, one particular level of Ala-
• Old age: more than 50 y
Tragus line should not be used while establishing occlusal plane for
Since the present study deals with the possible effect of soft
completely edentulous patients. According to age, different level of
tissue changes on level of ala-tragus line, age group intervals were
ala tragus line should be considered.
adopted from same study mentioned above Also, since most of
the edentulous patients are above 20 y of age, adult, mid and old
age groups were selected for present study. Number of completely References
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PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka, India.
2. Head and Professor, Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka, India.
3. Post Graduate Student, Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Gaurav Mathur,
Post Graduate Student, Department of Prosthodontics, SDM College of Dental Sciences and Hospital,
Date of Submission: Oct 27, 2014
Sattur, Dharwad-580009, Karnataka, India.
Date of Peer Review: Nov 21, 2014
E-mail: [email protected]
Date of Acceptance: Dec 18, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 01, 2015

42 Journal of Clinical and Diagnostic Research. 2015 Feb, Vol-9(2): ZC39-ZC42