J Indian Prosthodont Soc v133 2013 Sep PMC3732734 J Indian Prosthodont Soc 2013 Sep 133 142148 Published online 2013 Apr 25 doi 101007s1319101302880 PMCID PMC3732734 Occlusal Plane Location in Edentulous Patients A Review Sanath Shetty Nazia Majeed Zargar Kamalakanth Shenoy and V Rekha Author information Article notes Copyright and License information This article has been cited by other articles in PMC Abstract Occlusal plane orientation is an important factor in the construction of a complete denture Occlusal plane could be oriented using landmarks in the mandibular arch as well as in the maxillary arch In the mandibular arch there are few landmarks which could be used to orient the occlusal plane like the retromolar pad corner of the lips lower lip length whereas the maxillary arch has a number of landmarks of which the alatragal line is the most commonly used and the same being the most controversial In the following article different landmarks and its accuracy for orientating the occlusal plane Keywords Occlusal plane Orientation Alatragal line Introduction Complete denture prosthodontics is a challenge for the restoring dentist for the reason that rehabilitation of edentulous patients with conventional complete dentures be it tissue supported or implant supported has to be done by considering various biological and mechanical factors to restore functions and health of the stomatognathic system 1 Developing an occlusion that is compatible with functional movements of the stomatognathic system is one of the key factors in determining the prognosis of the completely edentulous patients 2 One of the important factors that help us in the establishment of ideal occlusion is the orientation of the occlusal plane Occlusal plane is the average plane established by the incisal and occlusal surfaces of the teeth it is not a plane but represents the planar mean of the curvature of the surfaces 3 Occlusal Plane Significance The correct orientation of the occlusal plane plays a vital role in optimal esthetic achievement In the natural smile the incisal tips follow the curve of the lower lip This effect is an expression of a correctly oriented occlusal plane if the occlusal plane hangs posteriorly the lipline viewed from the front will appear straight and contribute more than any other factor to the socalled denture look With the occlusal plane correctly oriented however the natural anterior curve will be achieved almost automatically and contribute a proper sense of perspective to the dental composition 4 The plane of occlusion forms an essential part of the concept of mechanically balanced articulation 5 The position of occlusal plane in denture wearers should be as close as possible to the plane which was previously occupied by the natural teeth 6 Such position of the occlusal plane provides normal function of the tongue and cheek muscles thus enhancing the denture stability 4 7 10 It is believed that teeth oriented on an occlusal plane in harmony with the individuals physiognomy is responsible in part all conditions being equal for stable retentive full dentures 11 Faulty orientation of the occlusal plane will jeopardize interaction between tongue and buccinators muscles 6 Where the occlusal plane is too high the tongue can not rest on the lingual cusps of the lower denture and prevent its displacement Also it forces the tongue into a new position that is higher than its normal position 12 This higher position of the tongue causes the floor of the mouth to raise and create undue pressure on the border of the lingual flange and results in partial loss of border seal 12 There is also tendency for accumulation of food in the buccal and lingual sulci 5 An occlusal plane that is too low could lead to tongue and cheek biting 4 Occlusal Plane Orientation Considering the importance of the accurate establishment of the location and inclination of occlusal plane on function esthetics and speech a method to conform it to the occlusal plane that existed in the natural teeth seems necessary The question which arises in clinical practice is how to discover which position was occupied by the natural occlusal plane after the loss of natural teeth and exactly how can the optimal position of the occlusal plane be found in every edentulous patient 13 The occlusal plane in anterior and posterior regions may vary and therefore these should be evaluated separately It is generally agreed that in the anterior region the vertical height of the occlusal plane is governed by esthetic requirements 6 14 and less frequently by functional demands 6 The anterior maxillary occlusal plane may be determined by lip relationships at rest and when smiling Speech also provides for positional accuracy 15 When viewed from the front the occlusal plane should be parallel to the interpupillary line 16 With regard to the orientation of the occlusal plane in the posterior region however there are contrasting views Various authors have postulated various landmarks for determining the occlusal plane Landmarks for Occlusal Plane Orientation in Mandibular Arch In the mandibular arch location of the occlusal plane is functionally related to mastication 15 Various landmarks have been used to orient the occlusal plane in the mandibular arch eg retromolar pad lateral borders of the tongue the buccinators grove and commissure of the lips Retromolar Pad The retromolar pad is divided into 2 or 3 parts by various authors Boucher 17 and Hall 18 recommended placing the occlusal plane such that it terminates posteriorly at the medial two thirds of the retromolar pad Piermatti 19 said the occlusal plane should terminate at the upper level of the retromolar pad while Rahn and Heartwell 20 said posterior height should not exceed half the height of the retromolar pad Engelmeier 21 said in the sagittal view the occlusal plane is determined by the approximate juncture of the upper and middle thirds of the retromolar pad Lundquist and Luther 22 determined the plane of occlusion in relation to the retromolar pad by placing a 16 gauge wire on the tip of the mandibular cuspid and by posteriorly extending the wire to the distolingual cusp tip of the second or third molar The relationship of the occlusal plane to the retromolar pad was determined by intersection of the wire and the pad In this study the pad was divided into two parts and it was found that in 75 of subjects the plane terminated in the lower half of the retromolar pad A study done by Shigli et al 23 used the same method as Lundquist and Luther 22 but divided the retromolar pad into three parts and found out that the mandibular occlusal plane coincided with the lower 13rd of the retromolar pad in majority of cases Ismail and Bowman 24 in their study made lateral cephalograms of dentulous patients on which the natural occlusal plane was marked After extraction of the natural teeth complete dentures where fabricated in which the occlusal plane was tentatively determined During teeth arrangement the middle third of the retromolar pad was used as reference for posterior plane Then on tracings of the cephalograms the palatal plane the natural occlusal plane and the prosthetic plane was marked and the relation was established They concluded that the occlusal plane should be modified by placing the second molars at the level of the upper third of the retromolar A study done by Gupta et al 25 used a metallic scale which passed along the cusp tip of cuspid to mandibular second or third molar and extended posteriorly to the retromolar pad They concluded that in maximum number of cases the occlusal plane coincided with the middle third of the retromolar pad The retromolar pad is a pear shaped area that forms only after the removal of the most distal molar 26 Also it is a soft tissue area and at times its anterior and posterior borders can not be demarcated accurately Therefore relying only on this one landmark can not guarantee complete validity to the occlusal plane orientation However when used as one of the guides for the occlusal plane orientation the area in the lower third of the retromolar could be used Lateral Border of the Tongue Yasaki 27 Nagle and Sears 28 suggested orienting the occlusal plane on the same level as the lateral border of the tongue to fulfill the theory that food is controlled on the occlusal table by the tongue A study done by Ghosn et al 29 made neutral zone moldings using phonation and found that the alatragus line extending from the inferior border of the ala of the nose to the inferior border of the tragus presented the closest relationship to the prosthetic occlusal plane corresponding to the lateral borders of the tongue The tongue is a highly movable organ in the oral cavity and thus its reliability in the occlusal plane orientation is questionable Also after extraction of all teeth the tongue becomes hypertrophied resulting in the change of the anatomy of the lateral border of the tongue Commissure of the Lips Lunquist and Luther 22 in their study used a stainless steel wire that was placed bilaterally on the occlusal embrasures between the mandibular cuspid and first premolar with minimal opening of the mouth to check the relation of the commissure of the lips to the occlusal plane It was observed in this study that the commissures where within a range of 13 mm either superiorly or inferiorly to the occlusal plane In a study done by Shigli et al 23 impressions were made with the help of an oral screen which extended to the distal aspect of the mandibular second molar on both sides They observed that the commissure of the lip was inferior to the occlusal plane by 137 mm Deciding on the commissure of lips as a guide for occlusal plane orientation is most unreliable as with age there is drooping or turning down of the corners of the mouth Therefore commissures can not be similar to as observed in dentulous patients Buccinator Groove A study done by Lunquist and Luther 22 made intraoral vestibular impressions with the help of a plastic screen which was cut to fit the labial and buccal vestibules without impinging the mucosa The relation of the buccinator groove was first established with respect to the commissure of the lips and then to the occlusal plane They found out that in 9095 of subjects the commissure of the lips was in the same plane as that of the buccinator groove and thus the occlusal plane is in the range of 13 mm to the commissure of the lips as well as of the buccinator groove Shigli et al 23 in their study used vestibular impressions with the help of an oral screen to determine the relation of the buccinator groove to the occlusal plane and found that the mean value of all readings of buccinators groove was 094 mm below the mandibular occlusal plane Gupta et al 25 used a custom made buccinator groove relator to compare the level of the buccinators groove to the occlusal plane They concluded that in 70 of males and 66 of females the occlusal plane was as the same level as the buccinator groove and can be used as a reliable landmark for orientation The buccinator groove could be a reliable landmark only in patients with good muscle tone as aging causes progressive loss of muscle tone Landmarks for Occlusal Plane Orientation in Maxillary Arch Various landmarks have been used to orient the occlusal plane in the maxillary arch eg parotid papilla hamular notch incisive papilla plane alatragus line Parotid Papilla Winkler 16 suggested that the parotid papilla is located 14th inch 6 mm above the occlusal surface of maxillary first molar teeth Lunquist and Luther 22 measured the distance with a different reference for the occlusal plane ie cusp tip of maxillary molars and suggested parotid papilla was located 4 mm above the occlusal plane Shigli et al 23 in their study found out that mean distance of parotid papilla was 256 mm above the maxillary occlusal plane They made impressions with the help of an oral screen which extended to the distal aspect of the mandibular second molar on both sides Foley and Latta 30 used the parotid papilla as a reference guide for occlusal plane orientation They examined dentulous patients to determine the distance of the occlusal plane from the inferior border of the right and left parotid papillae They found that the parotid papilla was 33 mm above the occlusal plane The above cited studies show that there is a sizable dissimilarity in the position of the parotid papilla ranging from 256 mm to 6 mm above the occlusal plane in dentulous subjects Therefore this landmark alone is not an accurate guide for occlusal plane orientation Hamular NotchIncisive Papilla Cooperman 31 and Rich 32 observed in their study that the occlusal plane showed a close relationship to the hamular notchincisive papilla plane Fu et al 33 in their study used a three dimensional surveying software to check parallelism between the hamular notchincisive papilla plane and four types of occlusal planes formed by different anterior and posterior reference points on maxillary teeth and found out that parallelism exists between the natural occlusal plane defined as mesialincisal edge of upper right central incisor and distalbuccal cusp tips of upper first molars and hamular notchincisive papilla plane Jayachandran et al 34 evaluated the reliability of the hamular notchincisive papilla plane HIP in establishing the occlusal plane The study was done both in dentulous as well as edentulous patients In dentate subjects the maxillary stone cast was mounted on the Wills surveyor with HIP made parallel to the horizontal plane using the tripoding method The vertical distance between the occlusal plane and floor of the surveyor was measured at four points When the measured values were equal the two planes were confirmed to be parallel for that situation In the edentulous subjects the occlusal plane established clinically using the alatragal line was Even though the hamular notch and the incisive papilla are constant landmarks and do not change over time this can not be easily used as a reliable tool to orient the occlusal plane in an edentulous subject as two planes can be parallel to each other at any height The cant of occlusal plane can be established but not the superoinfero position AlaTragus Line One of the most popular methods is to orient the occlusal plane parallel to a line drawn from the lowest point of the ala of the nose to the external auditory meatus or tragus Definitions of the alatragus line by different authors are a cause of confusion due to disagreement on the exact point of reference on the ala and the tragus for this line Clapp 35 in 1910 was the first to relate Campers lineplane to occlusal plane Numerous authors have stated as well as researched in this area and found out that all the three parts of the tragus ie superior middle and inferior have been proved to be guides for occlusal plane orientation in edentulous patients Superior Lloyd 16 Anthony 36 and Miller 37 define it as a line running from the inferior border of the ala of the nose to the superior border of the tragus Boucher 38 defines it as the line running from the inferior border of the ala of nose to the superior border of the tragus of the ear Trapozzano 39 40 used the upper border of the tragus as a reference point Gupta et al 25 in their study used a custom made occlusal plane analyzer to check the posterior reference point on the tragus and concluded that in 80 of female subjects the occlusal plane was found parallel to Campers plane with the anterior reference point as the ala of the nose and the posterior reference point as the superior part of the tragus Sadr et al 41 conducted a study in which the subjects were photographed in natural head position while clenching on a Fox plane After tracing the photographs the angles between the following lines were measured the occlusal plane Fox plane and the superior border of alatragus the occlusal plane Fox plane and the middle of alatragus as well as the occlusal plane Fox plane and the inferior border of alatragus It was found out that the superior border of alatragus line was almost parallel to the occlusal plane Al Quran et al 42 carried out a study to determine the most reliable alatragus line as a guide for the orientation of the occlusal plane in complete denture patients by the analysis of prosthodontically related craniofacial reference lines and angles of lateral cephalometric radiographs They concluded that the superior border of the tragus with the inferior border of the ala of the nose was most accurate in orienting the occlusal plane Middle Ismail and Bowman 24 describe it as a line passing from the ala of the nose to the center of the tragus of external auditory meatus Campers line which is an anthropologic measurement on skulls projected to the living head as a line passing from the ala of the nose to the center of the tragus of the external auditory meatus 43 Spratley 44 describes it as a line running from the center of the ala to the center of the tragus The Glossary of Prosthodontic terms 58 3 45 47 defines it as a line running from the inferior border of the ala of the nose to some defined point on the tragus of the ear usually considered to be the tip of the tragus A study done by Shigli et al 23 using a custom made occlusal plane relator concluded that the line drawn from the ala of the nose to the middle of the tragus was found to be parallel to the maxillary occlusal plane Gupta et al 25 in their study also fabricated a occlusal plane analyzer and concluded that in 72 of female subjects the occlusal plane was found parallel to Campers plane with the anterior reference point as the ala of the nose and the posterior reference point as the middle part of the tragus In a study of 2048 tragi forms Solomon et al 48 found that Campers plane was parallel to the occlusal plane when the tragus reference point was situated between the superior border and the middle of the tragus Inferior Simpson et al 49 state that it is a line running from the ala of the nose to the inferior border of the tragus A study carried out by Karkazis and Polyzois 7 also advocates the use of the inferior border of tragus as a posterior landmark Their cephalometric study concluded that the alatragus line or the Campers line extending from the lower margin of the ala to the inferior border of the external auditory meatus presented the closest relationship to the natural occlusal plane According to them the inferior border of tragus is an excellent equivalent soft tissue landmark to the lower border of external auditory meatus van Niekerk et al 50 constructed the plane of occlusion according to their subjective criteria of esthetics function and comfort The established plane of occlusion was then checked against the alatragus line only at the final denture insertion appointment Their results showed a close relationship between the two planes if the tragal reference of the alatragus line was dropped to the inferior border of tragus Cephalometric studies done by Rostamkhani et al 51 on individuals with Angles Class III Malocclusion and Sharifi et al 52 on individuals with Angles Class I jaw relation found out that the occlusal plane had a stronger tendency to be parallel to the line joining the ala of the nose and inferior border of the tragus Rostamkhani et al 51 in their study attached radiopaque markers to the intended points on the soft tissue of the tragus and then standard lateral cephalograms were obtained from each subject Cephalometric study done by Hindocha et al 53 found out that the tragal reference in their study population was more towards the inferior of the tragus They obtained lateral cephalograms after outlining the tragus and the base of the ala of the nose with radiopaque markers A study done by Hartono 54 made mirror photographs in a cephalometric laboratory to determine the part of the tragus to be used for marking the alatragus line and concluded that the line connecting the lowest part of the ala to the inferior margin of the tragus can be used as a guide to the orientation of the occlusal plane A study carried out by Chaturvedi et al 55 on dentulous and edentulous subjects to find out the most appropriate point on tragus to be used as a reference point at time of marking alatragus line while establishing occlusal plane also concluded that the inferior point is the most appropriate Lateral cephalograms of all subjects were taken The tragus was marked at all three points and three lines were formed by joining to the ala of the nose The angle formed by each line SA plane MA plane IA plane with Frankfort Horizontal FH plane was measured by using custom made device and modified protractor Study by Kumar et al 56 used digital photography in orthognathic profile patients to determine accurately the part of the tragus to be used to form the alatragal line and found out that the line joining from ala to the lower border of the tragus was parallel to the occlusal plane in 533 of the subjects The alatragus line is the most controversial landmark in occlusal plane orientation However this extraoral landmark is reliable as both its ends do not change with age Majority of the studies show that the line joining the inferior portion of the tragus with the ala of the nose is more often than not parallel to the occlusal plane Nonetheless the superior and middle part of the tragus can not be completely overruled as the lines formed with these landmarks and the ala of the nose have also proved to show parallelism with the occlusal plane Therefore a combination of more Other Methods of Orienting the Occlusal Plane Nagle and Sears 28 positioned the occlusal plane parallel to and in the midway between the residual ridges Swenson 57 states that the relative size and shape of the bearing area of the mandible and maxillae influences the decision as to the position of the occlusal plane Roberts 58 recommended positioning it halfway between the maxillary and mandibular ridges parallel to the Frankfort plane Nissan et al 59 conducted a cephalometric study on denture wearers to investigate the relationship between the anatomical structures eg retromolar pad occlusal plane and campers plane used to determine the occlusal plane and the facial skeletal shape They found out that there was no correlation between the facial skeletal shape and location of the anatomical structures Petricevic et al 60 did a study to evaluate whether the occlusal plane measurements on digital photographs were reliable for the reconstruction of occlusal plane Casts were mounted in the SAM 2 P articulator by a quick mount facebow transfer and angles between the articulator horizontal plane and the occlusal plane AHPOP recorded A Fox plane was placed over the maxillary dental arch and a quickmounting facebow was positioned and lateral digital photographs were taken The angles between the face bow and the Fox plane FBFP were measured Results showed that there was no significant difference between AHPOP and FBFP angles and thus concluded Conclusion Various landmarks are available for the orientation of occlusal plane in edentulous patients However based on the various studies done on dentulous patients no single method seems entirely accurate to locate the occlusal plane Therefore using one method alone will not suffice the determination of occlusal plane in edentulous patients A combination of various landmarks along with a judicious clinical judgment should be taken into account for the location of the occlusal plane in edentulous patients Contributor Information Sanath Shetty Email mocliamffideryttehsrd Nazia Majeed Zargar Email mocliamtohragrazmn Kamalakanth Shenoy Email mocoohaykklatned V Rekha Email mocliamg4891vahker References 1 DSouza N Bhargva K A cephalometric study comparing the occlusal plane in dentulous and edentulous subjects in relation to the maxillomandibular space J Prosthet Dent 1996 75 177182 doi 101016S0022391396900967 PubMed Cross Ref 2 Wright CR Evaluation of the factors necessary to develop stability in mandibular dentures J Prosthet Dent 1966 3 414430 doi 101016002239136690045X PubMed Cross Ref 3 Glossary of Prosthodontic Terms 2005 J Prosthet Dent 941 1092 PubMed 4 Monteith BD A cephalometric method to determine the angulation of the occlusal plane in edentulous patients J Prosthet Dent 1985 54 181 doi 101016S0022391385800767 PubMed Cross Ref 5 Posselt V Physiology of occlusion and rehabilitation 2 Oxford Blackwell 1968 6 Celebic A ValenticPeruzovic M Kralijevic K Brkic H A study of the occlusal plane orientation by intraoral method J Oral Rehabil 1995 22 233236 doi 101111j136528421995tb01569x PubMed Cross Ref 7 Karkazis HC Polyzois GL Zissis AJ Relationship between alatragus line and natural occlusal plane implication in denture prosthodontics Quintessence Intl 1986 17 4253 8 Landa JS A scientific approach to the study of the temporomandibular joint and its relation to occlusal disharmonies J Prosthet Dent 1957 7 170181 doi 1010160022391357900732 Cross Ref 9 Monteith BD A cephalometrically programmed adjustable plane a new concept in occlusal plane orientation for complete denture patients J Prosthet Dent 1985 54 388 doi 101016002239138590558X PubMed Cross Ref 10 Williams DR Occlusal plane orientation in complete denture construction J Dent 1982 10 4311316 doi 1010160300571282900240 PubMed Cross Ref 11 Swenson MG Complete dentures 2 St Louis The C V Mosby Company 1947 p 180 12 Wright CR Muyskens JH Strong LH Westerman KN Kingery RH Williams ST Study of the tongue and its relation to denture stability JADA 1949 39 269275 PubMed 13 Sinobad D The position of occlusal plane in dentulous subjects with various skeletal jaw relations J Oral Rehabil 1988 15 489498 doi 101111j136528421988tb00184x PubMed Cross Ref 14 Carey PD Occlusal plane orientation and masticatory performance of complete dentures J Prosthet Dent 1978 39 368 doi 101016S0022391378801486 PubMed Cross Ref 15 Robert M From prospective of facial esthetics in dental treatment planning J Prosthet Dent 1996 75 169 doi 101016S0022391396900955 PubMed Cross Ref 16 Winkler S Essentials of complete denture prosthodontics 2 St Louis Ishiyaku Euro America Inc 2004 17 Boucher CO Swensons complete dentures 5 St Louis The C V Mosby Company 1964 pp 246251 18 Hall WA Important factors in adequate denture occlusion J Prosthet Dent 1958 8 764775 doi 1010160022391358900969 Cross Ref 19 Piermatti J Tooth positions in full mouth restorations a case report Gen Dent 2006 54 209213 PubMed 20 Rahn AO Heartwell CM 1986 Textbook of complete dentures 5th edn Wolters Kluwer Co p 352 21 Engelmeier RL Complete denture esthetics Dent Clin North Am 1996 40 7184 PubMed 22 Lunquist DO Luther WW Occlusal plane determination J Prosthet Dent 1970 23 489498 doi 1010160022391370901988 PubMed Cross Ref 23 Shigli K Chetal B Jabade J Validity of soft tissue landmarks in determining the occlusal plane J Indian Prosthodont Soc 2005 5 139145 doi 1041030972405217107 Cross Ref 24 Ismail YH Bowman JF Position of the occlusal plane in natural and artificial teeth J Prosthet Dent 1968 20 407 doi 101016S0022391368800174 PubMed Cross Ref 25 Gupta RH Singh SP Relationship of anatomical landmarks with occlusal plane J Indian Prosthodont Soc 2009 9 3142147 doi 1041030972405257083 Cross Ref 26 Craddock FW Prosthetic dentistry a clinical outline 2 St Louis The CV Mosby Company 1951 27 Yasaki M Height of the occlusion rim and the interocclusal distance J Prosthet Dent 1961 11 2631 doi 1010160022391361901068 Cross Ref 28 Nagle RJ Sears VH Denture prosthetics 2 St Louis The C V Mosby Company 1962 p 134 29 Ghosn CA Zogheib C Makzoume JE Relationship between the occlusal plane corresponding to the lateral borders of the tongue and the alatragus line in edentulous patients J Contemp Dent Pract 2012 13 5590594 doi 105005jpjournals100241192 PubMed Cross Ref 30 Foley PF Latta GH Study of the position of the parotid papilla relative to the occlusal plane J Prosthet Dent 1985 53 124 doi 1010160022391385900800 PubMed Cross Ref 31 Cooperman HN HIP plane of occlusion in oral diagnosis Dent Surv 1975 51 6062 PubMed 32 Rich H Evaluation and registration of the HIP plane of occlusion Aust Dent J 1982 27 162 doi 101111j183478191982tb04081x PubMed Cross Ref 33 Fu PS Hung CC Hong JM Wang JC Threedimensional analysis of the occlusal plane related to the hamularincisivepapilla occlusal plane in young adults J Oral Rehabil 2007 34 136 doi 101111j13652842200601682x PubMed Cross Ref 34 Jayachandran S Ramachandran CR Varghese R Occlusal plane orientation a statistical and clinical analysis in different clinical situations J Prosthodont 2008 17 7572575 doi 101111j1532849X200800341x PubMed Cross Ref 35 Clapp GW Mechanical side of anatomical articulation New York The Dental Digest 1910 36 Sclar AG Soft tissue and esthetic consideration in implant therapy Carol Stream Quintessence Publishing Co Inc 2003 p 16 37 Miller GS Removable prosthodontics 1 New York BC Deckar Inc 1988 p 221 38 Boucher CO Current clinical dental terminology 2 St Louis The CV Mosby Company 1974 p 229 39 Trapozzano VR Occlusal records J Prosthet Dent 1955 5 325332 doi 1010160022391355900366 Cross Ref 40 Trapozzano VR Occlusion in relation to prosthodontics Med Clin North Am 1957 94 313325 41 Sadr K Sadr M A study of parallelism of the occlusal plane and alatragus line J Dent Res Dent Clin Dent Prospect 2009 3 4107109 PMC free article PubMed 42 Al Quran FA Hazzaa A Al Nahass N The position of the occlusal plane in natural and artificial dentitions as related to other craniofacial planes J Prosthodont 2010 19 8601605 doi 101111j1532849X201000643x PubMed Cross Ref 43 Wilder HH A laboratory manual of anthropometry Philadelphia Blakistons Son and Company 1920 p 4 44 Spratley MH A simplified technique for determining the occlusal plane in full denture construction J Oral Rehabil 1980 7 13133 doi 101111j136528421980tb01460x PubMed Cross Ref 45 Glossary of Prosthodontic Terms 1987 J Prosthet Dent 586 713762 PubMed 46 Glossary of Prosthodontic Terms 1994 J Prosthet Dent 711 41111 47 Glossary of Prosthodontic Terms 1999 J Prosthet Dent 811 39110 PubMed 48 Solomon EGR Sridhar Shetty Marla V Reliability of Tragus morphology and its reference to establish Campers plane J Indian Prosthodont Soc 2000 11 11622 49 Simpson JW Hesby RA Pfeifer DL Pelleu GB Arbitrary mandibular hinge axis location J Prosthet Dent 1984 51 6819822 doi 1010160022391384903834 PubMed Cross Ref 50 Van Niekerk FW Miller VJ Bibby RE Ala tragus line in complete denture prosthetics J Prosthet Dent 1985 53 167 doi 101016002239138590068X PubMed Cross Ref 51 Rostamkhani F Sahafian A Kermani H A cephalometric study on the relationship between the occlusal plane alatragus and Campers lines in patients with Angles Class III Malocclusion J Dent Tehran Univ Med Sci 2005 2 24649 52 Sharifi E Rostamkhani F A cephalometric study on relationship between occlusal plane and alatragus and Campers plane J Mashhad Dent Sch 2001 24 324112115 53 Hindocha AD et al A cephalometric study to determine the plane of occlusion in completely edentulous patients part I J Indian Prosthodont Soc 2010 10 4203207 doi 101007s131910110049x PMC free article PubMed Cross Ref 54 Hartono R The occlusal plane in relation to facial types J Prosthet Dent 1967 17 6549558 doi 1010160022391367901242 PubMed Cross Ref 55 Chaturvedi S Thombare R Cephalometrically assessing the validity of superior middle and inferior tragus points on alatragus line while establishing the occlusal plane in edentulous patient J Adv Prosthodont 2013 5 5866 doi 104047jap20135158 PMC free article PubMed Cross Ref 56 Kumar S Garg S Gupta S A determination of occlusal plane comparing different levels of the tragus to form alatragal line or Campers line a photographic study J Adv Prosthodont 2013 5 1915 doi 104047jap2013519 PMC free article PubMed Cross Ref 57 Swenson MG Complete dentures 2 St Louis The C V Mosby Company 1947 p 180 58 Roberts AL The effects of outline and form upon denture stability and retention Med Clin North Am 1960 4 293303 59 Nissan J Barnea E Zaltzer C Cardash HS Relationship between the occlusal plane determinants and craniofacial structures J Oral Rehabil 2003 30 587591 doi 101046j13652842200301044x PubMed Cross Ref 60 Petricevic N Guberina M Celic R Mehulic K Krajnovic M Antonic R Borcic J Celebic A Use of digital photography in the reconstruction of the occlusal plane orientation Med Glass 2009 6 2243248 Articles from The Journal of the Indian Prosthodontic Society are provided here courtesy of Medknow Publications

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O B I I O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O

occlusal plane orientation
oriented using landmarks
mandibular arch


Crit Care Res Pract v2014 2014 PMC3913483 Crit Care Res Pract 2014 2014 156814 Published online 2014 Jan 12 doi 1011552014156814 PMCID PMC3913483 Bedside Percutaneous Tracheostomy versus Open Surgical Tracheostomy in NonICU Patients Evgeni Brotfain 1 Leonid Koyfman 1 Amit Frenkel 1 Michael Semyonov 1 Jochanan G Peiser 2 Hagit HayunMaman 3 Matthew Boyko 1 Shaun E Gruenbaum 4 Alexander Zlotnik 1 and Moti Klein 1 Author information Article notes Copyright and License information Abstract Percutaneous bedside tracheostomy PBT is a one of the common and safe procedures in intensive care units through the world In the present paper we published our clinical experience with a performance of PBTs in the regular ward by intensive care physicians team We found it safe and similar outcome in comparison to open surgical tracheostomy method in operation room by ENT team The performance of PBT in the regular ward showed potential economic advantages in saving medical staff and operating room resources Go to 1 Introduction Over the last two decades percutaneous bedside tracheostomy PBT has been frequently performed in critically ill patients 1 2 Compared with the open surgical technique PBT has been implemented for similar clinical indications such as protection of the larynx and the upper airway as well as weaning from prolonged mechanical ventilation 3 4 PBT was demonstrated to be as safe as the conventional surgical approach in most critically ill patients 5 6 Moreover the overall rate of surgical bleeding and stomal infection was lower in the bedside technique compared with the open approach Both techniques have been shown to have similar mortality rates in the Intensive Care Unit ICU and in the inpatient wards 7 However the ventilation times and length of stay in the ICU following PBT were demonstrated to be significantly shorter 8 Bedside tracheostomy may be especially beneficial for patients who require prolonged mechanical ventilation Performing a bedside tracheostomy has become common practice in ICUs in Israel PBT can be performed quickly and safely by an ICU team trained and familiar with the procedure anesthesiologists intensive care physicians etc 6 and does not require the use of the operating room facilities Not surprisingly most bedside tracheostomies in the ICU are performed by intensive care physicians whereas only a minority was performed by ear nose and throat ENT surgeons In 2007 we published data reflecting our clinical experience of PBT procedure performed by intensive care physicians in the ICU 9 In Israel most mechanically ventilated adult patients are admitted to inpatient wards other than the ICU due to a shortage of ICU beds To circumvent this problem an Outreach PBT program was initiated by critical care physicians at our institution We anticipated that there would be economic advantages regarding the bedside procedure performance Go to 2 Materials and Methods In this study we retrospectively examined clinical data over six years and compared clinical data and economic analysis associated with the Outreach ICU PBT procedures performed in nonICU patients at our tertiary care center and the open surgical tracheostomy technique performed by ENT surgeons in the operating theater 21 Study Design This is an observational retrospective study performed in university teaching hospital 22 Study Comparators and Population The Human Research and Ethics Committee at Soroka Medical Center in Beer Sheva Israel approved this study We collected clinical data from all cases of tracheostomy performed at Soroka Medical Center between January 2006 and June 2012 Soroka Medical Center is a tertiary care facility with 1100 inpatient beds including 20 18 ICU beds Data from the percutaneous Outreach ICU program and open surgical tracheostomies performed in the operative theater were extracted from the Operating Room Registry 221 Exclusion Criteria Open surgical tracheostomies performed on pediatric patients as well as elective tracheostomies planned and performed by ENT surgeons were excluded 222 The ICU Outreach Team Protocol for Percutaneous Dilatational Tracheostomy All Outreach ICU procedures were performed according to our Outreach Team Protocol In the first step the treating team of the regular ward made the decision about tracheostomy Prior to performing the procedure patients were presented with written consent that included the clear indication for tracheostomy airway protection and weaning from prolonged mechanical ventilation Then all patients were examined by an intensive care physician prior to the procedure and clinical contraindications were excluded anatomical neck limitations significant coagulopathy morbid obesity presence of a pulsatile artery over the surgical area and inability to identify the cricoid cartilage Our ICU Outreach Team consists of 3 physicians one staff intensive care physician with at least twoyear experience in performing the procedure an assistant resident or ICU fellow physician and an anesthesiologist A registered nurse from the ward also assists in the procedure The Outreach Team uses standardized equipment for percutaneous dilatational tracheostomy Table 1 which is prepared and checked prior to beginning the procedure Table 1 Standardized set for percutaneous tracheostomy ICU Outreach Team Soroka Medical Center All PBTs are performed on intubated patients under adequate sedation and muscle relaxation and with administration of 100 oxygen Patients are monitored with an electrocardiogram noninvasive oscillatory blood pressure measurement pulse oximetry and capnography Equipment for emergent reintubation large size suction and a mechanical ventilator are prepared and checked before the start of the procedure The staff ICU physician is responsible for rechecking all equipment prior to beginning the procedure Prior to performing the procedure the availability of an ENT surgeon is confirmed in the event of complications A chest Xray is routinely done after PBT After performance of tracheostomy 223 Location The ICU Outreach Team was approved to perform PBT in all medical wards internal medicine neurology neurosurgery cardiothoracic and intensive cardiological care unit ICCU of Soroka Medical Center with the exception of the neonatal and pediatric departments 224 Methods All percutaneous Outreach ICU tracheostomies were done using the Portex Griggs method 10 without bronchoscopic assistance An ENT team in the operating room using the classic approach performed all open surgical tracheostomies 23 Data Collection 231 Variables and Measures The demographic data reasons for hospital admission indications for tracheostomy length of resources utilization complication rate and success rate of weaning from mechanical ventilation inhospital mortality and economic rationality of both methods were collected and analyzed from patients records in both groups 232 Economic Analysis The costeffective analysis of both the Outreach ICU and intraoperative procedures included the staff and operating room resources tracheostomy set cost and fee charges Length of resources utilization was defined as the time in minutes to perform PBT by the Outreach ICU Team including the time of the patients and setup position group 1 and the time from transferring the patient to the operating room until the patient returned to the ward group 2 It should be noted that the performance of tracheostomy in the operating room was always associated with additional events including transferring patients from the ward to Table 3 This time was included in the total time taken for an open surgical tracheostomy in the operating room Table 3 Outcome endpoints mean SD Staff and operating room resources included operating room time in OR cost dressing and sterile set materials in operating room and in the ward and staff physician time cost per hour ENT and anesthesia team in OR and Outreach ICU Team on the ward All economic analysis was estimated by the Hospital Financial Expert Service Group All costs were presented as a mean SD 24 Statistical Analysis Statistical evaluation of the results was done with the SPSS 18 package SPSS Inc Chicago IL USA Normally distributed data and continuous variable are presented by mean standard deviation SD Statistical comparisons between the two study groups for parametric data were conducted using Students t test Nonparametric data was analyzed with a 2 2 contingency table and a Fishers exact test Statistical significance was defined as P 005 Go to 3 Results A total of 685 tracheostomies were performed at our institution over a sixyear period and included elective semielective and emergent cases 70 patients group 1 underwent percutaneous bedside Outreach ICU tracheostomy by the intensive care physicians team and 615 patients underwent open tracheostomy by ENT surgeons in the operating room After applying the exclusion criteria 443 patients were included in the open tracheostomy group group 2 There was no difference in age distribution between the two study groups Table 2 Patients in group 2 had a higher incidence of sepsis whereas patients in group 1 had a higher incidence of acute stroke and intracranial hemorrhage P 005 Table 2 Table 2 Demographic data mean SD The length of resources utilization was significantly shorter in the Outreach ICU group compared with the open surgical tracheostomy group 20 85 min versus 775 147 min P 00001 Table 3 There were no statistically significant differences in the rate of successful weaning intraoperative complications or mortality between groups Table 3 Two cases of accidental falsepassage cannulation were encountered and successfully recannulated by the Outreach ICU Team during performance of the bedside procedure Complications during the open surgical approach included significant intraoperative bleeding accidental pneumothorax and misplacement of the cannula see Table 3 for details There were no intraoperative complications that resulted in patient deaths Intraoperative management of bleeding and pneumothorax included control of the bleeding and thoracic drainage respectively 31 Economic Rationale We found significant economic advantages to performing PBT by the Outreach ICU Team compared with open surgical tracheostomy in operating room Table 4 PBT was associated with reduced costs of medical staff resources compared to the open procedure P 00001 By examining the length of resources utilization between the two groups Tables Tables3 3 and and4 4 for details the bedside procedure may save significantly more operating room time annually Thus the annual economic analysis showed potential savings of approximately 50000 US by better utilizing the operating room resources total balance per procedure 338 10 US versus 561 10 US P 001 Table 4 Table 4 Economic rationale of PDT technique versus open surgical method in operating room mean SD Go to 4 Discussion PBT has become a widely performed bedside procedure in patients in the ICU Since its introduction in 1969 by Toy and Weinstein 11 multiple multicenter analyses and systematic reviews have been published comparing bedside tracheostomy to the standard surgical technique described by Jackson in 1909 7 8 10 12 In many countries there are a limited number of ICU beds 18 of all beds in our hospital 13 Many patients who required mechanical ventilation are usually treated in the regular wards 14 Moreover there is a considerable delay in the performance of open tracheostomy in the operating room by ENT surgeons due to a lack of available operating theaters and the relative high demand for elective and emergency procedures These delays may range in duration from two to 14 days As such this may result in a significant waiting time for tracheostomies performed by ENT surgeons which may subsequently prolong the hospital length of stay delay the weaning process 15 18 and increase patient morbidity 19 Despite detailed and large number of studies about using percutaneous bedside tracheostomy PBT method in critical care units we could not find any report about performance of PBT outside ICU in regular ward We found no differences in the intraoperative complication rate weaning success and survival rates between our Outreach ICU Team performance and the open surgical method in the operating room In contrast to Outreach ICU PBT performance group 1 where false passage cannulation occurred intraoperative complications in open surgical tracheostomy group 2 were related to intraoperative bleeding pneumothorax and accidental high tracheostomy placement However none were associated with fatal feature Otherwise the Outreach ICU Team required significantly less resources utilization time and was considerably cheaper than the open procedure in the operating room Similarly the Outreach ICU Team did not require the availability of an operating room or ENT team The costeffective analysis of both procedures demonstrated significant savings with regard to operating room and staff resources in the PBT compared to open surgical approach In contrast the tracheostomy sets were more expensive in the Outreach ICU group which has also been well described in the literature 20 Our study has a number of limitations We showed the prevalence of septic patients in open surgical tracheostomy group in contrast to acute neurological disturbances acute CVA intracranial bleeding in Outreach ICU group It might be explained by possible selection bias of use of retrospective data in the present paper This might be controlled for in a randomized prospective study Another limitation of our study is a major difference with respect to numbers in each group Also a precise economic analysis may be difficult to accurately analyze due to differences in time and logistics between procedures Future investigations might also include the detailed analysis of the operating room utilization resources benefit from saving charges and using free operating room time space for additional elective procedures examination of delayed complications length of ventilation and length of hospital stay In present study PBT has been demonstrated to be not only a safe procedure but also considerably cheaper than the open surgical method We believe that the economical and clinical advantages of PBT method are worth considering in patients who require tracheostomy Go to 5 Conclusion Performance of PBT in the wards should be considered safe if performed by physicians with the appropriate procedural skills PBT may also prevent subsequent complications associated with prolonged tracheal intubation We suggest that PBT may be more costeffective in terms of reducing the length of procedure and need for surgical staff and equipment Go to Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this article Go to Authors Contribution Drs Brotfain and Koyfman contributed equally to the paper Go to References 1 Koksal GM Sayilgan NC Oz H Percutaneous dilatational tracheostomy Middle East Journal of Anesthesiology 2006 18 5903910 PubMed 2 Schachner A Ovil Y Sidi J Rogev M Heilbronn Y Levy MJ Percutaneous tracheostomya new method Critical Care Medicine 1989 17 1010521056 PubMed 3 Kollef MH Ahrens TS Shannon W Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit Critical Care Medicine 1999 27 917141720 PubMed 4 Georges H Leroy O Guery B et al Predisposing factors for nosocomial pneumonia in patients receiving mechanical ventilation and requiring tracheostomy Chest 2000 113 767774 PubMed 5 Kilic D Findikcioglu A Akin S Korun O Aribogan A Hatiboglu A When is surgical tracheostomy indicated surgical Ushaped versus percutaneous tracheostomy Annals of Thoracic and Cardiovascular Surgery 2011 17 12932 PubMed 6 Klein M Weksler N Kaplan DM Weksler D Chorny I Gurman GM Emergency percutaneous tracheostomy is feasable in experienced hands European Journal of Emergency Medicine 2004 11 2108112 PubMed 7 Delaney A Bagshaw SM Nalos M Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients a systematic review and metaanalysis Critical Care 2006 10 2113 PMC free article PubMed 8 Griffiths J Barber VS Morgan L Young JD Systematic review and metaanalysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation British Medical Journal 2005 330 750212431246 PMC free article PubMed 9 Klein M Agassi R Shapira A Kaplan DM Koiffman L Weksler N Can intensive care physicians safely perform percutaneous dilational tracheostomy An analysis of 207 cases Israel Medical Association Journal 2007 9 10717719 PubMed 10 Walts PA Murthy SC DeCamp MM Techniques of surgical tracheostomy Clinics in Chest Medicine 2003 24 3413422 PubMed 11 Toy FJ Weinstein JD A percutaneous tracheostomy device Surgery 1969 65 2384389 PubMed 12 Freeman BD Isabella K Lin N Buchman TG A metaanalysis of prospective trials comparing percutaneous and surgical tracheostomy in critically III patients Chest 2000 118 514121418 PubMed 13 Mery E Kahn JM Does space make waste The influence of ICU bed capacity on admission decisions Critical Care 2013 17 3p 315 PMC free article PubMed 14 Hersch M Sonnenblick M Karlic A Einav S Sprung CL Izbicki G Mechanical ventilation of patients hospitalized in medical wards vs the intensive care unitan observational comparative study Journal of Critical Care 2007 22 11317 PubMed 15 Fikkers BG Fransen GAJ van der Hoeven JG Briedé IS van den Hoogen FJA Tracheostomy for longterm ventilated patients a postal survey of ICU practice in The Netherlands Intensive Care Medicine 2003 29 813901393 PubMed 16 Bouakl I BouKhalil P Kanazi G Ayoub C ElKhatib M Weaning from mechanical ventilation Current Opinion in Anaesthesiology 2012 25 14247 PubMed 17 Cox CE Carson SS Medical and economic implications of prolonged mechanical ventilation and expedited postacute care Seminars in Respiratory and Critical Care Medicine 2012 33 4357361 PubMed 18 Boynton JH Hawkins K Eastridge BJ OKeefe GE Tracheostomy timing and the duration of weaning in patients with acute respiratory failure Critical Care 2004 8 4R261R267 PMC free article PubMed 19 Hersch M Izbicki G Dahan D Breuer GS Nesher G Einav S Predictors of mortality of mechanically ventilated patients in internal medicine wards Journal of Critical Care 2012 27 6694701 PubMed 20 Grover A Robbins J Bendick P Gibson M Villalba M Open versus percutaneous dilatational tracheostomy efficacy and cost analysis American Surgeon 2001 67 4297301 PubMed Articles from Critical Care Research and Practice are provided here courtesy of Hindawi Publishing Corporation

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O