REVIEW ARTICLE

Posterior Reference Points: A Simplified Classification

Rahmath S Shafiullah1, Mahadevan Ravichandran2, Manoj K Sundar3, Venkatakrishnan Kamakshi4

A b s t r ac t​
Aim: The aim of this review is to summarize the pertinent literature concerning the most appropriate posterior reference point(s) to locate the
hinge axis and to arrive at a classification system.
Background: Numerous theories are proposed on the occurrence and the need to trace hinge axis, especially in prosthodontics, to restore lost
natural teeth. There is no classification system that exists in relation to posterior reference points.
Review results: Many authors have come up with various theories to locate the arbitrary hinge axis. The perplexing part in remembering these
posterior reference points are eliminated by arriving at a classification system.
Conclusion: Depending upon the anatomical landmark and the accuracy to the true hinge axis, a classification was formulated for ease of
understanding and learning purpose.
Clinical significance: Achieving a stable restoration requires the transfer of hinge axis as close to the true axis as possible. To enable this,
knowledge about the posterior reference points becomes mandatory. Since there are multiple posterior reference points, a classification system
would help ease in remembering them.
Keywords: Accuracy, Arbitrary hinge axis, External auditory meatus, Reference points, Tragus.
Journal of Scientific Dentistry (2019): 10.5005/jp-journals-10083-0913

B ac kg r o u n d​
1
Any occlusal rehabilitation warrants the orientation of the maxillae Department of Prosthodontics, Sri Venkateswara Dental College and
to that of the cranial base to restore proper form and function.1 Hospital, Chennai, Tamil Nadu, India
2
The maxilla is spatially positioned by identifying three different Department of Prosthodontics, Ragas Dental College and Hospital,
points to achieve a plane with the help of a facebow. 2,3 Horizontal Chennai, Tamil Nadu, India
3
reference plane is established by reference points anteriorly Department of Prosthodontics, Vokkaligara Sangha Dental College
and posteriorly, from which posterior occlusal determinants and Hospital, Bengaluru, Karnataka, India
and mandibular movements are established.4–7 Anteriorly, one 4
Department of Prosthodontics, SDM College of Dental Sciences and
reference point is located on the midface and posteriorly, reference Hospital, Dharwad, Karnataka, India
points are traced one on either side of the face in the area of Corresponding Author: Rahmath S Shafiullah, Department of
the transverse horizontal axis. 8 Hinge axis is an imaginary line Prosthodontics, Sri Venkateswara Dental College and Hospital,
connecting the center of rotation on the right and left mandibular Chennai, Tamil Nadu, India, Phone: +91 9840362006, e-mail: dentist.
condyle.4,5,9–11 [email protected]
How to cite this article: Shafiullah RS, Ravichandran M, Sundar MK,
Kamakshi V. Posterior Reference Points: A Simplified Classification. J Sci
C l i n i c a l ​ S i g n i f i c a n c e​ Dent 2019;9(1):9–12.
Hinge axis location significance: Source of support: Nil
• Enables transfer of the opening axis of jaws to that of the Conflict of interest: None
articulator, and to simulate the same arc of closure as that of
the patients’ mouth.9 which plane will be termed the reference plane while fabricating
• Used in diagnosis and treatment planning of mounted study a prosthesis.13,14 Many authors have come up with various
models.4 reference points, and to simplify the study process we have
• Helps in proper positioning of the casts in relation to classified the posterior reference points based on the anatomy
intercondylar shaft.4 and accuracy.10,15–17
• Hinge axis is the beginning of lateral mandibular movements.
• Alteration in vertical dimension is possible on the articulator. D i s c u s s i o n​
• To orient the maxilla and to determine the starting point for Shameem, Mahadevan, Manoj and Kamakshi (SMAKs)
functional movements of the mandible.2
Classification
• To check the accuracy of two centric records.12
Based on Anatomy of the Tragus of the Ear (TE)
Tragus of the ear is a commonly used anatomic reference.8,10,12,17,18
R e v i e w ​ R e s u lts​ Table 1 summarizes the posterior reference point based on the
Role of Posterior Reference Points anatomy of the tragus.
Posterior reference points are important in locating the hinge • Simpson—11 mm anterior to the superior border of the tragus
axis appropriately. The selection of three points in space defines on the camper’s line17 (Fig. 1).

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 Posterior Reference Points: A Simplified Classification

Fig. 1: Simpson’s point Fig. 2: Beyron’s point and Weinberg’s point

Fig. 3: Whipmix point and Bardnup Wongsen’s point Fig. 4: Schallorn’s point

• Beyron—13 mm anterior to posterior margin of tragus on line border of the tragus to the outer canthus of the eye10
from the center of tragus to the outer canthus of the eye8,17 (Fig. 6).
(Fig. 2). • Lundeen—13 mm anterior to the tragus on a line from the base
• Weinberg—11–13 mm anterior to the reference line drawn from of the tragus to the outer canthus of the eye.17
the middle and posterior border of the tragus8 (Fig. 2).
Middle of the tragus is almost parallel to the ala tragal line,
• Brandrup-Wognsen—12 mm anterior to most prominent point
among the generally suggested ala tragal reference. Of the seven
of posterior border of tragus16,19 (Fig. 3).
tragal references, ala tragal line was parallel to the occlusal plane
• Schallorn—13 mm from the posterior margin of the tragus to
in 41.5% situation when superior and middle border of the tragus
the canthus17 (Fig. 4).
were chosen. Also inferior border remained to be a poor reference.
• Bergstrom—10 mm anterior to the center of spherical insert
of the individual’s face bow and 7 mm below Frankfort plane17
Based on the Anatomy of the External Acoustic Meatus (EAM)
(Fig. 5).
External auditory meatus is another anatomic location to trace
• Denar—12 mm anterior to posterior border of the tragus
the hinge axis. Table 2 summarizes the posterior reference points
and 5 mm inferior to the line extending from the superior
based on EAM.20
• Lauritzen and Bodner identified a point 12 mm anterior to the
Table 1: Posterior references points with reference to tragus of the ear
middle of EAM and 2 mm inferior to the porion16 (Fig. 7).
Tragal reference Author/articulator • Whip mix articulator was in accordance to the design of the ear
Superior border Winkler, Swenson bow. In the anteroposterior direction at the anterior wall of EAM
Superior border Simpson and in the superior–inferior direction at the level of the most
Center of tragus Beyron prominent point of posterior border of tragus21 (Fig. 3).
Middle and posterior border Weinberg • Prothero came up with a point on a line from the superior margin
of the EAM to outer canthus of the eye intersecting with line
Posterior margin Shallhorn and Beck, Brandrup-
Wongsen
13 mm anterior to the anterior edge of EAM according to Richey’s
condylar marker16 (Fig. 7).
Posterior and superior border Bergstorm, Denar
• Gysi’s point is 13 mm anterior to the anterior margin of EAM on
Apex of tragus McGregor line from superior margin of EAM to outer canthus of eye17,22
Base of tragus Lundeen (Fig. 7).

10 Journal of Scientific Dentistry, Volume 9 Issue 1 (January–June 2019)

 Posterior Reference Points: A Simplified Classification

Fig. 5: Bergstorm’s point Fig. 6: Denar’s point

Table 3: Accuracy of posterior reference points within 5 mm radius

Investigator Accuracy (%)
Scallhorn 95
Beyron 87
Lauritizen and Bodner 33
Tetruck and Lundeen 33
Walker 20
Palik, Nelson, and White 50

opening axis of the articulator. Maxilla is oriented in space using

three reference points and thus it becomes essential for one to be
aware of the relative significance of posterior reference points for
any occlusal rehabilitation. Categorizing the numerous literatures
Fig. 7: Lauritzen and Bodner’s point, Prothero’s pont and Gysi’s point
on posterior reference points and simplifying this with the help of
a classification system would provide better understanding to the
Table 2: Posterior reference point with reference to external acoustic reader. Hence, in this review, classification based on the anatomy
meatus (EAM) and the accuracy has been formulated.
Position of EAM Author/articulator
Center Lauritzen and Bonder
Anterior wall Whipmix References
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Table 3 summarizes the accuracy of locating the posterior reference
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