Prosthodontic management of the curve of Spee: Use of the Broadrick flag

Christopher D. Lynch, BDS,a and Robert J. McConnell, BDS, PhDb National University of Ireland, Cork, Ireland
Proper management of the occlusal plane is an essential consideration when multiple long-span posterior restorations are designed. When restorations are added to an existing tooth arrangement characterized by rotated, tipped, or extruded teeth, excursive interferences may be incorporated, resulting in detrimental sequelae. The curve of Spee, which exists in the ideal natural dentition, allows harmony to exist between the anterior tooth and condylar guidance. An instrument called the Broadrick flag has been used to assist in the reproduction of tooth morphology that is commensurate with the curve of Spee when posterior restorations are designed; its use prevents the introduction of protrusive interferences. Consideration also must be given to lateral excursive movements when the occlusal plane is designed. In this article, the importance of the curve of Spee in prosthdontic and restorative dentistry is discussed, and a patient treatment demonstrating use of the Broadrick flag is described. (J Prosthet Dent 2002;87:593-7.)

n the normal natural dentition, there exists an anteroposterior curve that passes through the cusp tip of the mandibular canine and the buccal cusp tips of the mandibular premolars and molars, and that extends in a posterior direction to pass through the most anterior point of the mandibular condyle.1 Originally described by Ferdinand Graf Spee1 in 1890, this curve exists in the sagittal plane and is best viewed from a lateral aspect (Fig. 1); it permits total posterior disclusion on mandibular protrusion, given proper anterior tooth guidance. Spee located the center of the curve along a horizontal line through the middle of the orbits behind the crista lachryma posterior,2 a structure identified in the textbooks of the era3 as a vertical ridge on the lacrimal bone giving partial origin to the orbicularis oculi muscle. Spees idea was advanced in 1920 by George Monson.4 Based on anthropological observations, Monson described a 3-dimensional sphere that passed through the incisal edges and occlusal surfaces of the mandibular teeth. It is not usually noted that while Spee described a curve of approximately 2.5-inch radius (6.5-7.0 centimeters),1 Monson2 proposed the now widely accepted curve of 4-inch radius. Spee noted that it would be possible to locate the center of the curvature by reconstruction and measurement with the compass. The curve of Spee may be pathologically altered in situations resulting from rotation, tipping, and extrusion of teeth. Restoration of the dentition to such an altered occlusal plane can introduce posterior protrusive interferences.5 Such interferences have been shown to cause abnormal activity in mandibular elevator muscles, especially the masseter and temporalis muscles.6 This can be avoided by reconstructing the

Fig. 1. Curve of Spee. (Reproduced by Dr Mary McConnell from Spee FG. Die Verschiebungsbahn des Unterkiefers am Schdel. Arch Anat Physiol 1890;16:285-94)

aRegistrar, bProfessor,

Department of Restorative Dentistry. Department of Restorative Dentistry.

curve of Spee to pass through the mandibular condyle, which has been demonstrated to allow posterior disclusion on mandibular protrusion.7 As the angle of condylar guidance is greater than the curve of Spee, posterior disclusion is achieved.8 The Broadrick flag9 (Broadrick Occlusal Plane Analyser; Teledyne Water Pik, Fort Collins, Colo.) permits reconstruction of the curve of Spee in harmony with the anterior and condylar guidance, allowing total posterior tooth disclusion on mandibular protrusion. Its use assumes proper functional and esthetic positioning of the mandibular incisors. Should the anterior guidance be inappropriate, it must be redesigned prior to use of the Broadrick flag. The position of the designed restorations should not interfere with lateral excursive mandibular movements. The tooth arrangement in the bucco-lingual
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B
Fig. 2. A, Mounted diagnostic casts of patients right side. Mandibular right first molar was absent. Occlusal plane on this side was considered normal. B, Mounted diagnostic casts of patients left side. Marked discrepancy was evident in level of occlusal plane: mandibular left first molar was extruded, resulting in narrow occluso-gingival space for potential pontic to replace maxillary left first molar.

plane is referred to as the curve of Wilson.10 The curve of Monson4,11 is, in effect, a combination of the curves of Spee and Wilson in a 3-dimensional plane. This clinical report describes the effective application of the Broadrick flag in prosthodontic and restorative dentistry and reviews the principles of its use from anatomical science.

B
Fig. 3. A, Anterior survey point (ASP) was selected on midpoint of disto-incisal edge of mandibular left canine, from which long arc of 4-inch radius was drawn on flag with use of compass. B, Posterior survey point (PSP) was located on disto-buccal cusp of distal left mandibular molar. If position of this tooth were deemed unacceptable, anterior border of condylar element on articulator could be selected as PSP.

CLINICAL REPORT
A 26-year-old man seeking restoration of missing teeth in the maxillary left and mandibular right posterior quadrants was referred to the Restorative Department of the Cork University Dental School and Hospital (Wilton, Cork, Ireland). On clinical examination, it was found that the maxillary left second premolar, maxillary left first molar, and mandibular right first molar were absent. The endodontically treated maxillary left first premolar was fractured close to the gingival margin. Diagnostic casts were mounted in a semi-adjustable articulator (Denar Anamark Fossae; Teledyne Water
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Pik). Visual examination confirmed that the occlusal plane on the right side was normal (Fig. 2, A). After trial preparations and a diagnostic wax-up, a decision was made to restore this space with a combination fixed partial denture.12 However, a marked discrepanVOLUME 87 NUMBER 6

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B
Fig. 4. A, Short arc of 4-inch radius was drawn from PSP on flag to intersect long arc at center of curve of Spee. B, Point of compass was placed at center of flag, and 4-inch radius was drawn through buccal surfaces of mandibular teeth. Note extrusion of mandibular left first molar; mesial cusps of mandibular left second molar were below level of curve.

cy was noted in the level of the occlusal plane on the patients left side. The mandibular left first molar was extruded, resulting in a narrow occluso-gingival space for a pontic that would replace the maxillary left first molar (Fig. 2, B). The Broadrick flag was chosen to assess and, if necessary, redesign the level and orientation of the occlusal plane on the patients left side. The anterior guidance and esthetic appearance of the mandibular anterior teeth were assessed clinically and found to be satisfactory. The maxillary cast was removed from the articulator, and the flag was attached to the upper member of the articulator. The anterior survey point (ASP) was chosen on the midpoint of the disto-incisal edge of the mandibular left canine, from which a long arc of 4-inch radius was drawn on the flag with a compass (Fig. 3, A). Because the position of the distal mandibular molar was judged to be acceptable, the posterior survey point (PSP) was located on the distobuccal cusp of this tooth (Fig. 3, B), and a short arc was drawn on the flag to intersect the long arc at the center of the curve of Spee (Fig. 4, A). The point of
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the compass was placed at the center of the flag, and a 4-inch radius was drawn through the buccal surfaces of the mandibular teeth. The mandibular left first molar was markedly extruded, while the heavily restored mesial cusps of the mandibular left second molar were below the level of the curve (Fig. 4, B). On the stone cast, the occlusal surface of the mandibular first molar was reduced to the level of the redefined occlusal plane (Fig. 5, A). This tooth was planned for restoration with a gold onlay; the mandibular left second premolar with a metal-ceramic crown; the mandibular left second molar with a complete-coverage gold crown; and the maxillary left edentulous area with a 3-unit fixed partial denture, with the maxillary left first premolar and second molar as abutments. Trial preparations were performed on articulated duplicate casts, and the diagnostic wax-up was fabricated (Fig. 5, B). Care was taken to ensure even occlusal contacts in maximum intercuspation and avoid posterior interferences in protrusive or lateral excursions. The occlusion was restored to a canineprotected occlusion.
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Fig. 6. Definitive restorations cemented on left side.

B
Fig. 5. A, Occlusal surface of mandibular first molar reduced to level of redefined occlusal plane on stone cast. B, Diagnostic wax-up of restorations on patients left side.

DISCUSSION
The Broadrick flag is a useful tool in prosthodontic and restorative dentistry, as it identifies the most likely position of the center of the curve of Spee. However, this position should not be regarded as fixed or immutable. Esthetics and function place a considerable demand on the design of the occlusal plane. Compromise can be achieved by altering the length of the radius of the curve. In patients with a retrognathic mandible, a standard 4-inch curve would result in a flat posterior curve, causing posterior protrusive interferences. Such low mandibular posteriors would also lead to extrusion of the opposing maxillary teeth. If the maxillary posterior teeth were to be restored to this low occlusal plane, the crown-to-root ratio would be less than ideal. Hence, a 334-inch curve is more appropriate when a class II skeletal relationship exists. Conversely, a 4-inch curve would create a steep posterior curve in patients with a class III skeletal relationship, leading to further posterior interferences. A 5-inch radius would be more suitable in this situation. The center of the curve also may be varied to achieve the same effect. The center should always lie along the long arc drawn from the anterior survey point, but it may be moved in an anterior or posterior direction from the intersection of this arc with that drawn from the posterior survey point. This alteration will not affect the position of the anterior survey point, an important fact when the position of the mandibular anterior teeth is esthetically and clinically suitable.
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The diagnostic wax-up was duplicated, and vacuum-formed acrylic templates were fabricated. With use of the mandibular acrylic template, the mandibular left first molar was reduced intraorally to the occluso-gingival height predetermined on the diagnostic cast. Further occlusal reduction for a cast gold restoration then was performed and the onlay preparation completed. Cast dowel-and-core restorations were fabricated for the maxillary first premolar and mandibular second premolar and cemented in the normal manner. With the respective template as a guide, controlled conservative reduction was performed on the mandibular and maxillary left second molars. Provisional restorations were fabricated. After a 4-week trial period, the patient reported that the provisional restorations were comfortable. No abnormal wear facets were evident, occlusal contacts were present in MIP, no interferences in protrusive and lateral excursions were detected, and the gingival health remained optimal. Final restorations were fabricated in the traditional manner (Fig. 6). At subsequent recall appointments, the occlusion remained unchanged. The patient reported total comfort and satisfaction with the masticatory performance and esthetics of the definitive restorations.
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When the center of the curve or its radius is altered for esthetic reasons, care must be taken not to create new interferences. Needles7 noted that to ensure posterior disclusion on mandibular protrusion, the curve should extend through the condyle. When the PSP is located, the level and orientation of the distal molar tooth may not always be suitable. Should this be the scenario, it follows that the PSP may be taken as the anterior border of the condyle, represented by the most anterior point on the condylar element on the articulator. Care should be taken to ensure that the angle of the condylar guidance is not less than the curve of Spee, as this would introduce posterior protrusive interferences.8 It should be further considered that the arrangement of the maxillary and mandibular teeth influences lateral excursive movements. When viewed from a frontal aspect, the mandibular molars have a slight lingual inclination and the buccal cusps of these teeth are higher than the lingual. This arrangement is referred to as the curve of Wilson,10 and it facilitates lateral excursions free from posterior interferences. Attention should be paid to this principle when the diagnostic wax-up is designed. Monson4,11 proposed that the mandibular teeth should be arranged to close around a sphere of 4-inch radius, with the mandibular incisal edges and cusp tips touching the sphere, thus permitting protrusive and lateral excursions free from posterior interferences. It bears repeating that the now widely accepted 4-inch radius was proposed by Monson rather than Spee.4 Hyperactivity in the temporalis and masseter muscles has been demonstrated during mandibular protrusive movements when inappropriate posterior tooth contacts are present.6 Careful restoration design to ensure proper anterior guidance will prevent the introduction of such interferences and the establishment of such abnormal activity. Excursive interferences may result in wear, fracture of restorations, and temporomandibular joint dysfunction. The use of an acrylic template can facilitate controlled conservative reduction. In the clinical report presented, the template was a vital tool for transferring the designed blueprint from the diagnostic wax-up on the articulator to the mouth. The template allowed accurate reduction of the extruded mandibular first molar to the level of the redesigned occlusal plane, followed by appropriate reduction for the cast restoration. This ensured that the fabricated onlay was in harmony with the occlusal plane and that minimal tooth structure was removed. Acrylic templates also were used for conservative preparation of the other teeth.

of the curve of Spee. Extensive restorations designed with this tool permit mandibular excursions free from posterior interferences. Proper planning is required, but the predictability of a successful result can be enhanced by the use of a diagnostic wax-up, the transfer of information with an acrylic template, and the duplication of provisional restorations from the waxup. With use of the Broadrick flag, the prosthodontist can predictably produce high-quality restorations in harmony with the anterior and condylar guidance and avoid the introduction of possibly harmful sequelae to the patient.
We thank Ms Catherine MacGillycuddy, BA, HDE, MA, for her translation of Ferdinand Graf Spees article from German to English, and Dr Mary McConnell, B Dent Sc, for her reproduction of the curve of Spee in Figure 1. We acknowledge the assistance of Dr Michael Shanahan, BDS, in the preparation of the clinical treatment described.

REFERENCES
1. Spee FG. Die Verschiebungsbahn des Unterkiefers am Schdel. Arch Anat Physiol 1890;16:285-94. 2. Spee FG, Biedenbach MA, Hotz M, Hitchcock HP. The gliding path of the mandible along the skull. J Am Dent Assoc 1980;100:670-5. 3. Schfer EA, Symington J, Bryce TH. Quains elements of anatomy. London: Longmans, Green & Co; 1915. Vol. IV. Part I. p. 89. 4. Monson GS. Occlusion as applied to crown and bridgework. J Nat Dent Assoc 1920:7;399-413. 5. Shillinburg HT, Hobo S, Whitsett LD. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997. p. 85-6. 6. Williamson EH, Lundquist DO. Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983;49:816-23. 7. Needles JW. Practical uses of the Curve of Spee. J Am Dent Assoc 1923;10:918-27. 8. Needles JW. Mandibular movements and articulator design. J Am Dent Assoc 1923;10:927-35. 9. Bowley JF, Stockstill JW, Attanasio R. A preliminary diagnostic and treatment protocol. Dent Clin North Am 1992;36:551-68. 10. Wilson GH. A manual of dental prosthetics. Philadelphia: Lea & Febiger; 1911. p. 22-37. 11. Monson GS. Applied mechanics to the theory of mandibular movements. Dent Cosmos 1932;74:1039-53. 12. Chaffee NR, Cooper LF. Fixed partial dentures combining both resinbonded and conventional retainers: a clinical report. J Prosthet Dent 2000;83:272-5. Reprint requests to: DR CHRISTOPHER D. LYNCH DEPARTMENT OF RESTORATIVE DENTISTRY UNIVERSITY DENTAL SCHOOL AND HOSPITAL WILTON, CORK IRELAND FAX: (353)21-434-5737 E-MAIL: clynch85@hotmail.com Copyright 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 + 0. 10/1/125178

SUMMARY
The Broadrick flag is a valuable tool in prosthodontic and restorative dentistry, in that it locates the center
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