IMPORTANCE ATTAINMENT

LEONARD

OF AXIAL INCLINATIONS OF PARALLELISM

B.S., D.D.S.

OF TEETH IN

I. LINKOW,

New York, N. Y.

OF SKULLS, lateral plate roentgenograms, and diagnostic casts clearly indicate the difference in the angulation of the long axis of each tooth and to various planes of reference. A lack of understanding regarding this variability in the angulation of the crowns of the anterior teeth in relationship to those of the posterior teeth could inadvertently cause failure in the attainment of parallelism during preparatory procedures .l The penalty for failure to consider and provide for these irregularities of angulation will usually be failure to achieve perfect parallelism in the preparation of teeth for multiple restorations. Even a quite normal curve of Spee, when not taken fully into account in preparatory procedures, may cause failure. Prior to mouth preparation, certain adverse conditions and irregularities that may give rise to technical difficulties must be considered. These irregularities are: (1) abnormal relationship of maxillary teeth such as an extreme vertical or horizontal overlap (Fig. 1)) (2) crossbite relationships, (3) mandibular prognathism, (4) deep intercuspation, (5) occlusal disorganization from trauma, and (6) malocclusion caused by such factors as torsoversion, tilting, drifting, exfoliation, extrusion, intrusion, or incomplete eruption. (Fig. 2).

TUDIES

MAXILLARY

,4ND

MANDIBULAR

LATERAL

VIEW

STUDIES

The labial and lingual surfaces of the anterior maxillary and mandibular teeth of patients with Class I jaw relationships are seldom, if ever, parallel to the mesial and distal interproximal surfaces of the posterior teeth (Fig. 3). Similarly, the long axes of the anterior teeth are not parallel with those of the posterior teeth. This condition varies to a greater extent with the abnormal occlusions.
REASONS FOR NORMAL AND ABNORMAL AXIAL INCLINATION IRREGULARITIES

There is a sagittal occlusal curve of Spee in nearly all human dentitions (Fig. 4). Its purpose is somewhat questionable. Some believe that this curve provides balancing and strain-relieving contacts. Shawz believes that this sagittal curve is an economizer of space. I agree with this concept. Roentgenograms of deciduous teeth, the developing twelve-year molars, and third molars reveal the extreme tipping of these teeth to accommodate for the lack of space in the posterior part of the maxillae and mandible (Fig. 5).
517

LINKOW

J. Pros. Den. May-June, 1965

Fig. 1.

Fig. 2. in

Fig. l.-An extreme horizontal and vertical overlap of the anterior teeth. Fig. 2,Tilting, drifting, exfoliation, and extreme horizontal overlap must be considered the at ;tainment of parallelism of preparations.

Fig. 3.

Fig. 4.

Fig. 3.-Lateral plate roentgenograms reveal the differences in the axial inclinations of posterior teeth from those of anterior teeth. Fig. 4.-The long axes of the teeth of both jaws have a mesial inclination. Note the curve of Spee as seen in the sagittal plane.

Fig. 5.-The occlusal surfaces of the six and twelve of the mandible through which they will erupt.

year molars are parallel

to the surface

AXIAL

INCLINATIONS

OF TEETH

IN PARALLELISM

519

Fig. 6.-A tracing of a photograph of a skull reveals labiolingual tipping of the mandibular and maxillary anterior teeth, a mesial tipping of the mandibular molars, and either a mesial or distal tipping of the maxillary molars.

The teeth, under normal conditions, erupt nearly perpendicular to the alveolar ridge through which they enter the oral cavity. If the superior surface of the body of the mandible were completely flat or about one half of an inch longer anteroposteriorly, then the erupting teeth might all be perpendicular to the flat surface with their long axes parallel to one another. However, this condition does not exist. The occlusal and incisal surfaces of all the crowns in either dental arch do not contact a flat plane. From the side, the occlusal and incisal surfaces describe a curve that is concave for the mandibular teeth and convex for the maxillarv teeth (Fig. 4) .3 The profile view reveals the extreme labial tipping of the crowns of the maxillary incisors with the roots directed lingually, as they erupt at right angles to their bony segments. Similarly, the upper molars erupt at right angles to their alveolar bone. The roots of the upper molars curve distally while the crowns are either mesially or distally tipped. Therefore, the profile view of normal maxillae reveals either a mesial or distal tipping of the maxillary molar crowns in contrast with the labial flaring of the crowns of the maxillary incisors (Fig. 6). The inclinations of the maxillary cuspids and bicuspids lie somewhere between those of the molars and the incisors. However, the labiolingual relationship of the maxillary cuspids is seldom, if ever, parallel to the buccal surfaces of the molars. In certain instances, there are abnormal axial inclination irregularities of the teeth. The reasons for abnormal axial irregularities are : ( 1) an exaggerated curve of Spee as seen in many Class II malocclusions,4 (2) missing teeth without replacements that cause tipping, tilting, and rotation of the remaining teeth. (3) a disturbance in muscular equilibrium that causes unequal pressure on one segment of teeth, (4) a shifting of, breakdown of, or poorly constructed contact areas, and (S) functional and acquired habits.
REVEALING FACTORS IN DENTAL ROENTGENOGRAPHY

An essential feature of the long come technique in dental roentgenography is that the x-rays are directed at a right angle to the long axis of each tooth. The

LINKOW

J. Pros. Den. May-June, 1965

A B c D E

Plane of tooth Plane of film x-rays Film Occlusal plane

BICUSPID Fig. 7.-Differences in x-ray cone angulation are required to compensate in the buccolingual and labiolingual axial inclinations of the maxillary teeth.

MOLAR for the variance

Fig. S.-Frontal teeth.

roentgenograms

reveal

the buccolingual

axial

inclinations

of the posterior

film is held so that its plane is parallel to the long axis of the tooth.5 The variance that is required in angulations when the long cone technique is used clearly demonstrates the variance in the buccolingual and labiolingual axial inclinations of the teeth (Fig. 7). Lateral roentgenograms indicate the mesiodistal axial inclinations of posterior teeth and the labiolingual inclinations of anterior teeth. Anterior full-head roentgenograms reveal the buccolingual axial inclinations of posterior teeth (Fig. 8).
EVIDENCE FROM SKULL STUDIES

The increase in the size of the brain case in modern man takes place at the expense of his face.6 Mans jaw has become smaller, and while his teeth are smaller than those of his progenitors, the teeth have not decreased in size as rapidly as have their maxillary and mandibular bony bases. Hence, occlusal irregularities, some normal and some abnormal, are common. There seems to be insufficient space for 32 teeth in most mouths. My examinations of the profile views of 63 human skulls* revealed that, although the roots of the anterior maxillary teeth tipped linguopalatally and the
*Clay Adams Laboratories, Inc., New York, N. Y.

X::re: 3

AXIAL

INCLINATIONS

OF TEETH

IN PARALLELISM

5211

roots of the posterior teeth tipped distally, the crown positions showed interesting variety. In 31 of the 63 skulls, the crowns of the maxillary molars were tilted in the same mesial direction as the labial inclination of the crowns of the anterior teeth, although to a lesser degree (Fig. 9). In 16 of the skulls, the crowns of the maxillary molars were on a line perpendicular to the floor, with the assumption that the plane of occlusion was parallel to the floor (Fig. 10). In the final 16 skulls, the crowns of the maxillary molars were inclined distally in an opposite direction to those of the anterior maxillary teeth (Fig. 11). Crown angulations of the left side varied with those of the right side on the same skull in 11 instances. Anterior views of 9 different skulls revealed that in four of them the buccal surfaces of the posterior teeth were nearly parallel with the labial surfaces of the cuspids (Fig. 12). In 2 of the skulls, the buccal surfaces of the posterior teeth were more lingually directed than the labial surfaces of the cuspids (Fig. 13). In the other 3 skulls, the buccal surfaces of the maxillary posterior teeth inclined farther buccally than the labial surfaces of the upper cuspids (Fig. 14). A palatal view of the maxillae revealed the labially angulated crowns of the anterior teeth and the buccally angulated crowns of the posterior teeth (Fig. 15).

Fig. 9. Fig. 9.-The Fig. lO.-The maxillary maxillary

Fig. 10. molar crowns are inclined in a mesial direction. molar crowns are perpendicular to the plane of occlusion.

Fig. 11.

Fig. 12.

Fig. Il.-The maxillary molar crowns are inclined distally in relation to the anterior teeth. Fig. 12.-The buccal surfaces of the maxillary molars and bicuspids are on the same plane as the cuspids.

J. Pros. Den. May-June, 1965

Fig. 13. Fig. 13.-The Fig. 14,The bicuspids and molars have a greater lingual maxillary bicuspids and molars have a greater

Fig. 14. inclination than the cuspids. buccal flare than the cuspids.

Fig. 15.-The crowns of the posterior rior teeth are inclined labially. PROCEDURAL CONSIDERATIONS

teeth are inclined

buccally.

The crowns

of the ante-

IN THE ATTAINMENT

OF PARALLELISM

Clinically, whether or not the maxillary posterior crowns tip mesially, distally, or remain perpendicular to the plane of occlusion, preparations in them must be made to be parallel with the prepared anterior teeth. The distoproximal slices of the maxillary molars must be acutely angulated so that they are in a plane that is parallel with the prepared labial surfaces of the anterior teeth (Fig. 16). The degree of angulation of the slices depends on ( 1) the degree of angulation of the prepared labial surfaces of the anterior teeth, and (2) the degree of angulation of the posterior teeth themselves. The importance of obtaining parallelism between the buccal surfaces of the posterior teeth with each other and with the labial surfaces of the cuspids cannot be underestimated. This procedure should be accurately and carefully executed. A lateral plate roentgenogram exposing the angulation of all the teeth in both jaws is advised prior to full arch splinting. The roentgenogram reveals the difference in axial inclinations of the anterior with the posterior teeth and permits the angulation of the mesiodistal slices posteriorly and the labiolingual slices anteriorly to be determined. When anterior teeth are severely tipped, patients should be advised of possible mechanical pulpal exposures in order to attain passive paral-

AXIAL

INCLINATIONS

OF TEETH

IN PARALLELISM

52.3

x
a.

- Prepared

labial

surface

/ b.

Fig. 16.-The diagram demonstrates the disc angulation needed to prepare the distalproxima1 surface of a maxillary molar so it could be parallel with the prepared surfaces of a Prepared anterior maxillary tooth. a, Axial inclination of maxillary incisor. b, Angulation of disc for distoproximal slices parallel to prepared labial surfaces. (z).

lelism of the preparations. Similarly, the mesial proximal surfaces of the mandibular molars should be prepared parallel with the prepared labial surfaces of the mandibular anterior teeth.
SUMMARY AND CONCLUSIONS

Differences in the angulation of the long axes of natural teeth with one another and to various planes have been described. Certain conclusions are related to this information. These are : 1. The proximal slices on the distal surfaces of all maxillary molars, bicuspids, and cuspids should be made at an angulation that is parallel with the prepared labial surfaces of the maxillary incisors. If these surfaces of the posterior teeth are merely made perpendicular to the occlusal plane, then attainment of parallelism with preparations in the anterior teeth cannot be accomplished. 2. The usual mesial axial inclination of mandibular crowns necessitates that the mesioproximal surfaces of these teeth be prepared with a severe distal angulation toward the occlusal surface in order to make them parallel to the prepared mandibular anterior teeth. 3. Buccolingually and labiolingually, all the teeth must be tapered toward the occlusal and incisal surfaces to insure parallelism from an anteroposterior view. 4. Parallelism in the preparation of abutment teeth means parallelism from every aspect. The prosthesis must be fitted into position with complete passiveness and must not act as an orthodontic appliance. 5. No line angles should remain on the preparations. They should be cylindrical and tapered in form to create parallelism with the loss of a minimal amount of tooth structure.
REFERENCES L. I.: Full Arch Fixed Oral Reconstruction Simplified, New York, 1962, Springer Publishing Company, p. 33. 2. Shaw, D. M.: Form and Function in Teeth, Internat. J. Orthodont. 10:703-718, 1924. 1. Linkow,

524

LINKOW

J. Pros. Den. May-June, 1965

3. Wheeler, R. C.: Textbook of Dental Anatomy and Physiology, Philadelphia, 1940, W. B. Saunders Company, pp. 42-44. 4. Berliner, A. : Clinical Periodontology; Dynamics and Treatment, New York, 1953, The Park Press, p. 222. 5. Schweitzer, J. M. : Oral Rehabilitation; Complete Occlusal Reconstruction, Treatment of Dental Deformities, and Related Subjects, The Closed Bite, St. Louis, 1951, The C. V. Mosby Company, p. 687. 6. McCall, J. O., and Wald, S. S.: Clinical Dental Roentgenology; Technic and Interpretation Including Roentgen Studies of Child and Adolescent, ed. 3, Philadelphia, 1952, W. B. Saunders Company, pp. 67-71. 745 FIFTH
NEW YORK, AVE. N. Y.