A STUDY TO EVALUATE THE HORIZONTAL CONDYLAR … · 2019. 8. 15. · condylar path is the path traveled by the mandibularcondyle in the temperomandibular joint during various mandibularmovements

A STUDY TO EVALUATE THE HORIZONTAL

CONDYLAR INCLINATION IN DENTULOUS

PATIENTS USING CLINICAL AND TWO

RADIOGRAPHIC TECHNIQUES

Dissertation submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the Degree of

MASTER OF DENTAL SURGERY

BRANCH I

PROSTHODONTICS AND CROWN & BRIDGE

APRIL 2019

ACKNOWLEDGEMENT

This dissertation is the result of work with immense support from many people

and it is pleasure now that I have the opportunity to express my gratitude to all of

them.

I would like to convey my heartfelt gratitude and my sincere thanks to my

Head of the department, Professor, Dr. Shyam Mohan A, M.D.S., D.N.B.,

Department of Prosthodontics and Crown & Bridge, for his exceptional guidance,

tremendous encouragement, well-timed suggestionsand heartfelt support throughout

my postgraduate programme, which has never failed to drive the best out of me. I

would like to profoundly thank him for giving an ultimate sculpt to this study. I will

remember his help for life.

I also express my deep sense of gratitude and my sincere thanks to

Dr.Aarti Rajambighai MDS, Reader, Dr Ramesh Raja MDS, Reader, Dr. Joephin

Soundar MDS, Reader, Dr.A.Niazahammed MDS, Senior lecturer,

Dr.Sarathchandragovindraja MDS, Senior lecturer, Dr.Shyma rose P.D, MDS,

Senior lecturer, for their timely assistance and help throughout the study.

It is my extreme pleasure to extend my gratitude to my beloved chairman

Dr. Jacob Raja for his valuable support and constant encouragement throughout the

period of my study.

It gives me immense pleasure to convey my deep indebtness to our respected

Principal, Dr.Cynthia Sathiasekhar, Administrative Director, Dr. I Packiaraj, Vice

Principal (Academics), Dr. Antony selvi, Vice Principal (Administration),

Dr. J. Johnson Raja, and Members of the Ethical Committee and Review Board

for the permission, help and guidance throughout the course.

TABLE OF CONTENTS

S. NO.

CONTENTS

PAGE NO.

1

INTRODUCTION

1

2

AIMS AND OBJECTIVES

5

3

REVIEW OF LITERATURE

6

4

MATERIALS AND METHODS

16

5

RESULTS

33

6

DISCUSSION

40

7

SUMMARY

46

8

CONCLUSION

48

9

BIBLIOGRAPHY

49

LIST OF FIGURES

S.NO FIGURES PAGE NO

1 Materials used 24

2 Hanua articulator & facebow 24

3 OPG 25

4 CBCT 25

5 Facebow transfer 26

6 Direct mounting – frontal view 26

7 Direct mounting – lateral view 27

8 Maxillary casts mounted 27

9 Protrusive wax record – frontal view 28

10 Protrusive wax record – right lateral view 28

11 Protrusive wax record – left lateral view 29

12 Articulator with interocclusal record 29

13 Articulator with interocclusal record – lateral view 30

14 HCI measurement 30

15 HCI measurement illustration – OPG 31

16 HCI measurement – OPG – SidexisXG software 31

17 HCI measurement – CBCT – NNT viewer 32

LIST OF TABLES

S NO DESCRIPTION PAGE NO

1 Mean value of HCI measurements of three

groups : clinical, OPG and CBCT.

35

2 Inter group comparison using ONE WAY –

ANOVA

35

3 Post hoc comparison of three groups : clinical,

OPG, CBCT

36

4 Mean value of three groups subjected to

correlation test for left side.

37

5 Pearson correlation test to determine the

correlation between three groups on the left side.

37

6 Mean value of three groups subjected to

correlation test for right side

38

7 Pearson correlation test to determine the

correlation between three groups on the right

side

38

LIST OF GRAPHS

S NO DESCRIPTION PAGE NO

1 Bar diagram indicating comparisons of right

and left HCI for three groups

39

Introduction

INTRODUCTION

1

A Prosthesiswill be harmonious only when there is no premature contacts or

occlusal interferences during centric &eccentric mandibular movements. Eccentric

mandibular movements includes protrusive and laterotrusive movements of the

mandible. Movements of the mandible is partially controlled by the movement of the

condyle along the glenoid fossa, popularly known as the condylar path.

condylar path is the path traveled by the mandibularcondyle in the

temperomandibular joint during various mandibularmovements – GPT -8

Movement of the condyle in the antero-posterior direction is guided by the

articular eminence slope, commonly known as sagittal condylar guidance. Inclination of

sagittal condylar guidance, i.e., Horizontal condylar inclination varies with each

individual, including age and gender variations.

Literature reveals that horizontal condylar inclination will be steeper or higher in

younger individuals, and it decreases with age. Likewise , horizontal condylar inclination

values will be higher for males compared to females.

Influence of horizontal condylar inclination over the occlusion of the patient is

always overlooked by the clinician. Most often, clinicians follow average condylar

settings for programming the articulator during the fabrication of prosthesis. Average

horizontal condylar inclination values that has been usually followed by the clinicians

are in the range of 30º to 40º.( Posseit& Nevstedt1 1961, Gerber & Steinhardt

2 1990,

Lamb3 1993). Literature suggests that following the average condylar settings for the

occlusal rehabilitation of the patient, starting from single crown to multi-unit fixed

prosthesis could result in premature contacts and occlusal interferences.

INTRODUCTION

2

Clinician should be aware of maligned effect of average condylar settings and

hence it should not be followed blindly. The state of patient may be either dentulous or

edentulous, accurate measurement of horizontal condylar inclination should be done and

used for programming the articulator. Using the higher values than the patient’s own

value could result in protrusive and lateral occlusal interferences. Whereas, using the

lower value shows interferences in the articulator that does’nt exist in the patient4.

Hence, it is mandatory for the clinician to measure the horizontal condylar

inclination of the patient, before fabricating the prosthesis. Numerous methods have been

proposed to measure horizontal condylar inclination by previous studies such as

protrusive interocclusal record method, graphic tracing method etc.

With evolving technologies, new innovations such as mechanical pantographic

device, electronic pantographic device, axioquick system, jaw motion analyser and

Cadiax compact, horizontal condylar inclination of the patient can be measured.

In mechanical pantographic device, horizontal condylar incination will be

measured by drawing a tangent drawn to a curve made on the flags attached to the

patient’s face during mandibular movements. In case of electronic pantographic device,

the graph will be generated electronically with the help of motion sensors.

Axioquick system uses ultrasonic sensors to capture the mandibular movements

and hence the curve is produced. HCI is measured by drawing a tangent to the curve. Jaw

motion analyser and Cadiax compact uses the similar principles to measure the

horizontal condylar inclination.

INTRODUCTION

3

The drawbacks of the above mentioned techniques and technologies are its time

consuming, highly technique sensitive. Accurate measurement is doubtful due to the

possibility of human error. The operator should be aware of the mechanical principles of

the device and should be expertise in handling it to measure the horizontal condylar

inclination.

To overcome the shortcomings of the pantographic devices and other HCI

measuring devices, diagnostic x rays can be used to measure horizontal condylar

inclination. Literature suggests that panoramic radiographs can be used to measure the

horizontal condylar inclination.

Panoramic radiograph (OPG) is the most common diagnostic aid in the field of

prosthodontics. Panoramic radiographs were used to evaluate alveolar ridge height in

edentulous patients, root remnants, pathology associated with tempero-mandibular joint,

bony exostoses. Usage of panoramic radiograph as a tool to measure horizontal condylar

inclination has been proposed by various authors such as Christensen and slabbert5 in

early 80’s itself.

Horizontal condylar inclination can be measured in reference to Frankfort

horizontal plane, which can be easily traced on the radiograph. The radiographic method

is simple , less time consuming and cost effective.

The reliability of accurate measurements of horizontal condylar inclination by

panoramic radiograph is questioned. HCI measurements depends on the ability of the

operator to delineate the margins of the glenoid fossa and the articular eminence and to

trace it on the radiograph.

INTRODUCTION

4

Very few studies were documented in the literature, comparing panoramic

radiograph method with clinical method such as protrusive interocclusal record method.

Digital imaging such as cone beam – computed tomography is gaining popularity

and applications in the field of implant dentistry, because of its high precision and

accuracy. Studies regarding the use of CBCT to determine horizontal condylar

inclination is very much limited.Sumbullu et al used CBCT to measure horizontal

condylar inclination . But the author’s aim was to measure the variation in horizontal

condylar inclination values in healthy individuals compared to patients with tempero-

mandibular disorders.

Studies comparing clinical and radiographic techniques are very much

limited.Reliability of the clinical over the two radiographic techniques is debatable and

demands further studies. Thus the present study was taken up with anull hypothesis

stating that no significant differences existed between the clinical and the two

radiographic techniques.

Aim and objectives

of the study

AIMS & OBJECTIVES

5

• To evaluate the horizontal condylar inclination ( HCI) in dentulous subjects

by clinical methods and two radiographic methods namely OPG and CBCT.

• To assess the reliability of the clinical over the radiographic techniques

• To assess the reliability of CBCT over clinical method

• To assess the reliability between radiographic techniques

• To find a correlation between clinical and radiographic techniques

Review of literature


6

CBCT STUDIES :

Sümbüllü MA et al6 examined articular eminence morphology radiographically

using cone beam CT considering age and gender of the healthy patients and subjects with

TMJ dysfunction . The articular eminence inclination and height of 52 TMJ dysfunction

( 11 males and 41 females) and 41 control patients ( 17 males and 24 females) were

measured on CBCT images. Statistically significant difference in eminence inclination

and height were seen on healthy patients .the eminence inclination was steep between

age groups of 21 and 30 and decreased after 30 years of age. According to gender,

eminence inclination and height were statistically insignificant.

Kwon OK et al7 conducted a study to find a correlation between SCGAs

measured using three types of radiographic images (panoramic, CBCT panoramic-

section, and CBCT cross-section images) and the protrusive occlusal record. The study

included 20 patients aged 20 - 40 years with a complete set of teeth, class I molar

relation, and 2 - 4 mm of overjet, with available anterior guidance within the normal

range and no temporomandibular disorders. The protrusive occlusal record method

involved two operators calculating the average after making two measurements on an

articulator independently. Radiographic measurements were 2 - 10 degrees higher than

those from the protrusive occlusal record. The values obtained using panoramic

radiograpgh were 8-9 degrees higher than the protrusive occlusal record, whereas the

values of CBCT panoramic-section and CBCT cross-section measurements being 5 - 6

degrees higher. Therefore, in this study, subtracting 6 degrees from the SCGA measured

using CBCT images seems to be reasonable for clinical applications.

Shreshta P et al8 compared the horizontal condylar guidance values measured

using radiographic and clinical methods.The condylar guidance value of 12 patients aged


7

between 20-40 years irrespective of sex was radiographically measured using CT scan

and three clinical methods i.e. the wax protrusive records, Lucia jig record and intraoral

central bearing device. The records were taken and transferred on the semi-adjustable

articulator to record the HCG values. 3D reconstruction of the mid facial region was

obtained from CT scan. Frankfort horizontal plane (FHP) and a line extending from the

superior anterior most point on the glenoid fossa to the most convex point on the apex of

articular eminence (AE) was marked on the CT scan. An angle between these two lines

provided both right and left sides condylar inclination angle. Values obtained from CT

scans were higher than those of the clinical methods,

CBCT evaluation of condylar position in edentulous subjects were done by

Veloso L et al9. twenty healthy edentulous subjects were exposed to CBCT scanning

twice using static and dynamic registrations. Static registration were made by manually

guiding the chin to position the condyle in the articular fossa at required vertical

dimension of occlusion. Inter-maxillary position was maintained with rigid impression

material. Dynamic registration was made by means of gothic arch tracing. Comparatively

, dynamic registration produces a favorable physiologic condylar position than static

registration.

PROTRUSIVE WAX RECORD AND OPG STUDIES :

TannamalaPK et al10

Condylar guidance values were measured on ten subjects

with no signs and symptoms of temperomandibular disorder using protrusive record

method and panoramic radiograph method. In protrusive inter-occlusal record method,

maxillary casts were mounted on Hanua articulator by means of facebow transfer,

initially. Protrusive records were made by asking the patient to protrude the mandible by

6mm. condylar guidance value was calculated on the semi-adjustable articulator with the


8

help of protrusive record. In panoramic radiographic technique, angle was measured

between two planes, Frankfort horizontal plane and mean curvature line. The mean

curvature line is formed by connecting the most superior point on the glenoid fossa and

the inferior most point on the curvatures. Right and left side condylar guidance values of

both inter and intra group comparisons were not statistically significant. Study revealed

that HCG values of panoramic radiograph was 4 degrees higher than those of clinical

method. And it concluded that values measured on the panoramic radiograph can be

helpful in programming the semi-adjustable articulator.

Galagali Get al11

One hundred twenty dentulous subjects between 20 – 40 years

of age, devoid of temporomandibular disorder were selected. Condylar guidance values

were obtained from semi-adjustable articulator using protrusive inter-occlusal record.

HCG values were measured radiographically in reference to Frankfort horizontal plane in

both panoramic and lateral cephalogram. Results indicated that HCG values obtained

from lateral cephalogram were closer to clinical method , when compared to panoramic

radiograph. High quality and less distortion on the right and left side TMJ of lateral

cephalogram might be the reason.

Paul R et al12

An in-vivo study included sample size of about twenty edentulous

subjects of either sex between 45 and 75 years of age. Horizontal condylar guidance

(HCG) values were determined clinically by protrusive inter-occlusal record along with

intraoral gothic arch tracing on semi-adjustable articulator and radiographically by means

of panoramic radiograph and lateral cephalogram. HCG values obtained from

cephalometric tracing of diagnostic radiographs can act as supporting aid but cannot be

used primarily for programming semi-adjustable articulator.


9

Prasad KDet al13

In 75 dentulous subjects, sagittal condylar guidance values

were measured by protrusive inter-occlusal record and orthopantomogram. Aluwax was

used as inter-occlusal record. In semi-adjustable articulator, casts are mounted by means

of facebow transfer and sagiattal condylar guidance values were determined with the

help of protrusive inter-occlusal record. In orthopantamogram, the angle was measured at

the point of intersection of two planes, one connecting the orbitale and porion i.e,

Frankfort horizontal plane and the other joining the heights of curvature in the glenoid

fossa and the corresponding articular eminence. Results showed statistically significant

difference between the two groups. Panoramic radiographic tracings of sagittal condylar

path guidance can be used to set the values in semi-adjustable articulator.

GilboaI et al14

An in-vitro study conducted on 25 human skulls. Panoramic

radiographic technique and measurements made directly on the impressions of the

glenoid fossa and articular eminence were the two techniques employed. In panoramic

radiographic technique, initially prior to imaging , two metal wires were adapted in such

a way that , inner thicker wire was adapted to the middle of the most concave part of the

articular eminence in antero-posterior direction. The outer thinner wire was fixed to the

inferior aspect of the zygomatic arch adjacent to the articular eminence. Tracings were

done and the angles were measured. Measurements made were evaluated twice by 2

operators. Mean difference inclination of up to 7 degrees were found between impression

technique and panoramic radiograph technique.

KaurS et al15

30 human skulls were included in the study for the measurement of

condylar guidance angle. On the middle of the most concave point of the glenoid fossa

and along the inferior aspect of zygomatic arch, two solder wires were adapted. Then, the

skulls were subjected to panoramic imaging. With the wires in place, impressions of the


10

glenoid fossa and articular eminence were made using poly vinyl siloxane impression

material. Orientation of the glenoid fossa is done by incorporating FHP with the help of

HANUA facebow while making impression. Impressions were sectioned and the

condylar guidance angle was measured on the imprints of the impression. Measurements

made on both right and left side of the skull were subjected to statistical analysis.

Compared to anatomical method, radiographic technique showed condylar inclination

value of about 4.52* and 4.45* higher on the left and right side respectively.

Curtis DA et al16

compared HCI values measured on an articulator by

pantographic tracings with protrusive records obtained by two intraoral recording

materials, (Regisil) a polyvinyl siloxane material and a laminated, metalized wax

(Coprwax wafers). Study includes 12 women and eight men without any signs of

temperomandibular disorder. Conventional pantographictechniques were followed with

kinematic hinge axis to record pantographic tracings. Six protrusive records were

obtained for each patient, three with Regisil material and three with Coprwax wafers.

The average condylar inclination recorded were as follows: pantograph (29.5 degrees),

Regisil material (28.3 degrees), Coprwax wafers (25.8 degrees). Instead of single

protrusive record, three protrusive records reduced the probability of error. Condylar

inclination values obtained with pantographic tracings were higher than that of protrusive

interocclusal records.

PANTOGRAPHIC TRACING STUDIES :

dos Santos Jr J et al4Ten subjects involved in the study were selected in

accordance to the school’s division of occlusion criteria. All ten subjects were healthy

and had no signs of temperomandibular disorder. Condylar guidance settings were

obtained using an extra-oral tracing and protrusive wax record. The wax protrusive


11

record was obtained when the patient protruded the mandible to 6mm from centric

relation, as it is confirmed on the Hanua articulator by the anterior movement of condylar

spheres up to 6mm on both sides. The pantographic tracings were made using Hanua

facebow, intraoral clutch adapted to the mandibular arch and a holder frame with

bilateral flags on the either side where the protrusive movements were traced by means

of inscribing pointers. Results concluded that condylar guidance values measured using

pantographic tracing were higher compared to protrusive wax record.

Ratzmann A et al17

compared two methods of obtaining horizontal condylar

inclination (HCI ) measurements i.e., protrusive inter-occlusal record and an electronic

pantographic device, the Jaw Motion Analyzer (JMA). Twenty-three individuals (12

females; 11 males; mean age 46.7 years) were subjected to both methods. Initially, a

protrusive inter-occlusal wax record was taken after 5 mm protrusive movement was

made by the subjects and with the help of 2 different articulators (SAM 2; Reference SL)

HCI angles were measured. Jaw motion analyzer records the protrusive jaw tracks when

the protrusive movement is made, from which kinematic hinge axis and HCI angles were

determined. The mean HCI values obtained using JMA was statistically significant and

comparatively high with that of protrusive wax record. The JMA proved to reliable and

seems to be a promising tool for setting articulators than protrusive wax records.

Pelletier LBet al18

compared the accuracy and reliability of various methods

involving different bite registration materials, pantography device and simple jaw motion

analyzer. The bite registration materials used were wax, polyether, and zinc oxide. The

pantography device were mechanical pantography (Denar pantography) and electronic

pantography (Denar pantronic). Other devices were mandibular movement analyzer, the


12

mini recorder, the quick set recorder. Electronic pantography provided the accurate

result. PretiG et al

19 studied the relevance of graphic registration method with that of

radiographic method and intraoral or positional wax method. In graphic registration

method, Gerber’s graphic registration instruments were used and data were obtained.

Condylar sagittal pathway traced by graphic registration method found to be reliable and

accurate in healthy individuals, whereas the variation in degrees in repeated

measurements exceeds 5 degrees in case of patients with temperomandibular disorder.

Posselt Uet al20

The purpose of this investigation is to analyse and compare the

results of graphic registration method with that of intraoral wax record method. Condylar

rods of the facebow were used to mark the tracings on the cards in this technique, called

as Gysi technique. Mean value of condyle path inclination obtained using intraoral wax

method in 10 young patients is 30.3º, whereas for the gysi technique is 36.3º. The

difference in angulation is attributed to the difficulty in drawing a tangent to the curved

condylar path.

El-Gheriani ASet al21

came up with different methods of analyzing graphic

tracings of condylar path inclination. Three methods employed were 1) tangent method

2) mathematical method 3) the B- spline curve fitting technique. Mathematical method

works on the basis of trigonometric functions, drawing points along the curve and

measuring the slope using the mathematical formula. B- spline curve fitting technique

incorporates algebraic cubic polynomials and the angle was calculated based on the

formula. Measurements were conducted on arab, Caucasian and Malaysian population.

Mathematical and B spline curve fitting technique provided more accurate results than


13

tangent method. B spline curve fitting technique is complicated and needs more

understanding to expertise.

Accuracy of cadiax compact, an electronic hinge axis tracing device has been

tested by Celar AGet al22

. Hinge axis tracer was attached to articulator. Artex reference

SL articulator was preset to HCI values of 20º, 40º and 60º and hinge axis movements

were simulated. Also, the Bennett angles were preset to 0 º, 5 º,10 º, 15 º. Measurement

difference range upto 3.4 º and statistically significant. Differences were clinically

acceptable and low compared to other methods previously documented

Johnson A et al23

rejected the use of average condylar inclination settings on the

articulator and proposed a method of measuring the same using mandibular facebow.

With the use of mandibular facebow attached by means of clutch to the lower jaw,

sagittal condylar path were marked on the graph with pencil styli. Angle measurements

were made by drawing a tangent to the curve. Values obtained were reliable and

accurate. Variation in individual operator repeatability following this technique was 1.7º.

Prasad KD et al24

evaluated the reliability, repeatability and validity of the

Axioquick system. The Axioquick system (ultrasonic axiograph) comprises of

mandibular facebow with clutch attached to lower jaw, having four ultrasonic

transmitters and maxillary facebow having eight ultrasonic sensors which records the

mandibular jaw movements. the datas obtained using sensors were represented in

graphical and numerical values using computer software. In comparison to the other

technique used, i.e., protrusive wax method, axiograph produced angles 8.8º higher.

Chang WSet al25

did an experimental study to authenticate the use of Cadiax

Compact, a new electronic pantographic device. Device was used to calculate condylar

settings on 5 different articulators (Denar D5A, Denar Mark II, Whip Mix 8500, Hanau


14

Modular, and Panadent PCH).Probability of error with Cadiax Compact is relatively

small and it is proven to be effective and accurate in measuring horizontal condylar

inclination.

TYPES OF ARTICULATOR & ITS INFLUENCE :

Prajapati Pet al26

believed that difference in angle measurements exists when

different anterior reference points were used with different type of articulators. To

investigate its effect, maxillary casts were mounted in 2 types of articulators ARCON

and NON-ARCON, using anyone of the following anterior reference points. 1) orbitale

2) superior annular groove in the incisal pin 3) inferior annular groove in the incisal pin.

Results suggested that superior annular groove should not be used as third point of

reference, whereas the other two can be used, irrespective of type of articulator used.

Gross M et al27

conducted a pilot study on two male subjects to evaluate the

effect of different recording materials and 3 types of articulators on condylar inclination

measurements. Whipmix, Hanua 158 and Denar Mark II were the 3 articulators used.

Base plate wax, copper wax and self-curing resin were the 3 registration materials used.

Sagittal condylar guide settings were highest for Denar Mark II compared to Hanua 158.

Recording materials used does’nt have any influence.

GoyalMK et al28

assessed the variation in sagittal condylar guidance

measurements of twenty healthy individuals by arcon ( Hanua Wide-Vue) and non arcon

(Hanua H2) and validated it against the digital cephalogram. The mean sagittal condylar

guidance values of arcon articulator were in close approximation with cephalometric

tracings. Reason quoted was anatomic simulation of temperomandibular joint by arcon

articulator.


15

Changes in inclination of the condylar path, as the age increases is not well

documented. Sreelal T et al29

aimed at 1) analyzing the age changes in horizontal

condylar guidance values by means of cephalometric tracings 2) to compare it with

clinical method to find the significant difference 3) to found the difference on light and

left side horizontal condylar inclination values. The cephalometric tracings includes

superimposition of two images 1) image taken at centric occlusion 2) image taken at

protrusive position. On the superimposed image, angle was measured between the

Frankfort horizontal plane and a line connecting shifting positions of the condyle.

Horizontal condylar inclination values decreases with age. There is no significant

difference between cephalometric tracing and clinical method, so whichever method can

be used to measure the condylar guidance.

Materials and

methods


16

The present in-vivo study was conducted for the comparative evaluation of the

accuracy of horizontal condylar inclination measurements in dentulous subjects using

clinical and radiographic methods viz i) Protrusive wax record ii) Panoramic radiograph

iii) Cone beam – computed tomography imaging.

MATERIALS USED : ( figure 1 )

1. Bite registration material ( Registrado Xtra, VOCO)

2. Aluwax ( MAARC dental products, Mumbai, India )

3. Tropicalgin ( Zhermack , Italy)

4. Kalstone ( Kalabhai, Germany)

5. Elite arti ( Zhermack, Italy)

INSTRUMENTS USED :

1. Semi-adjustable articulator( HANAU Wide – Vue Articulator, Whip Mix

Corporation, USA) ( Figure 2)

2. Face bow ( HANAU spring bow, Whip Mix Corporation, USA)( Figure 2)

3. Honigum automix dispensing gun – type 50, 1:1 ( DMG America)

4. Bard parker knife no : 3

5. Bard parker blade no : 15

6. Dentulous perforated impression trays ( GDC fine crafted dental pvt ltd, India )

7. Cheek retractor

EQUIPMENTS USED :

1. Panoramic radiograph ( SIRONA, Germany ) ( Figure 3 )

2. Cone beam – computed tomography ( Newtom , Italy) ( Figure 4)


17

METHODOLOGY:

I. FORMULATION OF STUDY DESIGN :

The present in-vivo study is about the evaluation of horizontal condylar

inclination in dentulous subjects. As evident in the literature, protrusive

wax record, clinical method to measure horizontal condylar inclination

was designated as the gold standard. Comparisons were made to

determine the reliability, repeatability and validity of CBCT evaluation

along with panoramic radiograph evaluation in doing the same. Subjects

are divided into three groups :

Group 1 : Clinical method using wax record

Group 2 : OPG evaluation

Group 3 : CBCT evaluation

Considering the parameters involved in the study, statistical test was

conducted to calculate the desired sample size. Statistical test employed

was CI – estimates the sensitivity of the study. With Precision(%) and

Desired Confidence level (1-α)% expected to be 10 % and 95 %

respectively, the estimated sample size for the present study was found

to be 25.

a) Inclusion criteria :

i. Age group : 18 – 30 years

ii. Dentulous healthy subjects

iii. Angle’s class I occlusion

iv. Full dentition excluding third molars ( minimum 28 teeth)


18

v. Commitment to participate in the study understanding the effects

of radiation.

b) Exclusion criteria

i. Individuals with compromised dentition:

1. Grossly decayed teeth

2. Grossly filled teeth

3. Missing teeth

4. Replaced teeth

ii. Tempero mandibular disorders

iii. History of orthodontic treatment

iv. Poor neuromuscular coordination

v. Medical conditions contradicts radiation exposure.

vi. Pregnancy

vii. History of muscular disorder

viii. Conditions or circumstances that would prevent completion of

study participation or interfere with analysis of study results (eg.

Non – compliance)

c) Informed consent.

The study proposal was presented before the ethical committee( Reg.

no. DE-3(44)-93/2246) and institutional review board of the study center and

clearance was obtained for the proposal. All the subjects who fulfilled

the above inclusion and exclusion criteria were counseled regarding the

diagnostic investigation procedure and the research element involved in

it. Participant’s doubt regarding the procedure has been clarified. A


1

written consent was obtained from those subjects who were willing to

participate in the study.

II. PATIENT SELECTION :

Dentulous healthy subjects who reported to Rajas medical institution were

screened to fulfill the inclusion and exclusion criteria. Importance of the

diagnostic procedure has been explained well to the subjects. Based on the

clinical assessments, the final population of 25 subjects ( male = 16, female = 9)

was selected.

III. CLINICAL METHOD:

Once the clinical assessment of the selected subjects is done, diagnostic

impressions were made with stock trays ( GDC fine crafted dental pvt ltd, India ) using

irreversible hydrocolloid impression material ( Alginate - Tropicalgin, Zhermack, Italy).

Study casts were fabricated using type III dental stone ( kalabhai kalstone, Germany).

a) Facebow transfer: ( figure 5)

Using HANAU spring bow( Whip Mix Corporation, USA), facebow

transfer was done as follows : RegistradoXtra (VOCO) bite registration

material was used to position the bite-fork firmly to the upper arch.

Orbitale was the chosen anterior reference point for placing the U shaped

frame. Ensuring the paralleling of the following three planes i) patient’s

inter pupillary line ii) U shaped frame iii) bite fork, screws were tightened

and facebow transfer was completed and ready to be transferred to the

semi-adjustable articulator.

Direct mounting was done by placing the earpieces of facebow to the

auditory pins of semi – adjustable articulator ( HANAU Wide – Vue


20

Articulator). Maxillary casts were mounted to the articulator by means of

mounting plaster (Elite arti, Zhermack, Italy). Mandibular casts were

mounted with patient’s own maximum inter-cuspation record.( figure 6,

7, 8)

b) Protrusive wax record ( figure 9, 10, 11)

Subjects involved were instructed to protrude the mandible bringing

anterior teeth to an edge to edge position with the midlines aligned. At the

protrusive edge to edge position , protrusive wax record was obtained

using Aluwax ( MAARC dental products, Mumbai, India ). Protrusive

wax record’s excess was trimmed using B.P blade no 15. A total of 3

protrusive records were taken for each individual to reduce the possibility

of operator error. All the procedures were carried out by the same

operator.

c) HCI measurement ( figure 12, 13, 14)

Once the centric locks of the semi-adjustable articulator were loosened,

maxillary and mandibular casts were tapped to slide into the protrusion

with protrusive wax record in place. The articulator is then held close to

the body and gently tapped for complete seating of the casts in the wax

record. The position is reassured and confirmed before measuring the

horizontal condylar inclination measurements. Measurements were made

thrice using the three protrusive records separately and mean value is

taken for each individual.


21

IV. OPG method:

a) Imaging the subject: ( figure 3)

Panoramic imaging of the subjects involved was done using themachine (

SIRONA, Germany ). Head position was standardized for all the subjects

in such a way that Frankfort horizontal plane was made parallel to the

floor. Infra red light aligns the head of the subject according to the

standard protocol and held firmly in position throughout the radiation

exposure using head holders. All images were acquired at 80-90 Kvp and

5-7 mA.

b) Software analysis : ( Figure 15, 16)

Horizontal condylar inclination, an angle between Reference plane OP

and Reference plane SI, was measured using the software ( Sidexis XG,

Sirona, Germany). Reference plane OP is nothing but the Frankfort

horizontal plane, a line connecting the inferior most point on the orbit,

Orbitale and the superior most point on the external auditory meatus,

Porion. Reference plane SI indicates the mean curvature line, projected

path travelled by the condyle, i.e., a line connecting the superior most

point on the glenoid fossa (S) and the inferior most point on the articular

eminence (I). lines were drawn and angular measurements were made

using the analytical tools in the software. Measurements were done on the

both left and right side of the subject. Images were analysed by the same

operator.


22

V. CBCT method :

a) Imaging the subject: ( Figure 4)

Cone beam – computed tomography scanning was carried out in

machine( Newtom , Italy). Patient’s head position was standardized

throughout the course of the procedure. Frankfort horizontal plane was

made parallel to the floor. TMJ view was conducted separately for right

and left sides for each individual. As a result, two exposures were made

for each subject. Exposure was made by the same operator, according to

the manufacturer’s instructions, at 90kvp, 5.0 mA.

b) Software analysis: ( Figure 17)

Images were reconstructed using NNT viewer. 0.150 mm thick slices

were prepared and cross-section was done at the center of the condyle

along the sagittal plane. In the cross-sectional image, two reference planes

were drawn. One, connecting the superior point of the external auditory

meatus and the inferior most point on the articular eminence. The Other ,

connecting the superior most point on the glenoid fossa and the inferior

most point on the articular eminence. Angle was measured at the point of

intersection of these two planes. Measurements were made by the single

operator.

VI. Tabulation of data & statistical analysis :

Horizontal condylar inclination measurements were measured and tabulated

groupwise. The tabulated data was subjected to statistical analyses to fulfill

the objectives of the study. Statistical analysis was done using the software

SPSS for Windows (version 17.0)


23

Clinical method OPG method

Case selection ( n = 25)

&

Informed consent

Formulation of study design

Inclusion & Exclusion criteria

CBCT method

Horizontal condylar

inclination measurements

Tabulation of Results

Statistical Analysis

METHODOLOGY – OVERVIEW


24

Fig 1 Materials used

Fig 2 Hanua Articulator & Hanua facebow


25

Fig 3 OPG – Patient’s position

Fig 4 CBCT – Patient’s position


26

Fig 5 Facebow transfer

Fig 6 Direct mounting – frontal view


27

Fig 7 Direct mounting – lateral view

Fig 8 Maxillary casts mounted


28

Fig 9 Protrusive wax record – frontal view

Fig 10 Protrusive wax record – right lateral view


29

Fig 11 Protrusive wax record – left lateral view

Fig 12 Articulator with interocclusal record


30

Fig 13 Articulator with interocclusal record – lateral view

Fig 14 HCI measurement


31

Fig 15 HCI measurement illustration - OPG

Fig 16 HCI measurement – OPG – SidexisXG software


32

Fig 17 HCI measurement – CBCT – NNT viewer

Results

RESULTS

33

The data collected were tabulated and subjected to statistical analyses.

Mean value of HCI on the left and right side of the subject following three

methods were calculated separately.

Mean value of left HCI obtained from 25 subjects in the clinical method is

29.800, ranging from 20.0 minimum to 35.0 maximum. Mean value of left HCI in OPG

method is 35.960, with a range of 26.4 to 41.8. Mean value of left HCI in CBCT method

is 31.132, with a range of 21.7 to 36.2. (Table 1)

Mean value of right HCI obtained from 25 subjects in the clinical method is

29.800, ranging from 20.0 minimum to 35.0 maximum. Mean value of right HCI in OPG

method is 35.856, with a range of 26.8 to 43.5. Mean value of right HCI in CBCT

method is 30.968, with a range of 21.2 to 36.9. (Table 1)

Measurements were tested for significance using ONE-WAY ANOVA test

(p < 0.01). Significant difference exists between groups as revealed by the statistical test

(P = 0.000) on both the sides i.e., left and right HCI. (Table 2)

Post hoc intergroup comparison test was done to statistically found the

significance between the two groups (P< 0.05). Significant difference exists between

clinical and OPG method (P = 0.000) and also between the OPG and CBCT method.

(0.000). whereas no significant difference was seen between clinical and CBCT method

(P = 0.520). (Table 3).

Correlation of HCI measurements on the left side between three groups were

analysed using Pearson correlation test (P < 0.01). Mean values of three groups on the

left side for correlation test were expressed in table 4. Pearson correlation test revealed

RESULTS

34

that significant correlation existed between three groups (P = 0.000) as expressed in

table 5.

Correlation of HCI measurements on the right side between three groups were

analysed using Pearson correlation test (P < 0.01). Mean values of three groups on the

right side for correlation test were expressed in table 6. Pearson correlation test revealed

that significant correlation existed between three groups (P = 0.000) as expressed in

table 7.

RESULTS

35

Table 1 : Mean value of HCI measurements of three groups :

Clinical, OPG and CBCT.

Descriptive

N

Mean

Std.

Deviation

Std.

Error

95% Confidence

Interval for Mean

Minimum

Maximum

Lower

Bound

Upper

Bound

LEFT HCI CLINICAL METHOD 25 29.800 4.4441 .8888 27.966 31.634 20.0 35.0

OPG 25 35.960 4.2309 .8462 34.214 37.706 26.4 41.8

CBCT 25 31.132 4.2220 .8444 29.389 32.875 21.7 36.2

Total 75 32.297 5.0090 .5784 31.145 33.450 20.0 41.8

RIGHT HCI CLINICAL METHOD 25 29.800 4.4441 .8888 27.966 31.634 20.0 35.0

OPG 25 35.856 4.2107 .8421 34.118 37.594 26.8 43.5

CBCT 25 30.968 4.7049 .9410 29.026 32.910 21.2 36.9

Total 75 32.208 5.1293 .5923 31.028 33.388 20.0 43.5

Table 2 : Inter group comparison using ONE WAY - ANOVA

ANOVA

Sum of

Squares df

Mean

Square F

Sig.

P<0.01

LEFTHCI BetweenGroups 525.245 2 262.623 14.202 .000

Within Groups 1331.434 72 18.492

Total 1856.679 74

RIGHTHCI BetweenGroups 516.099 2 258.050 12.985 .000

Within Groups 1430.796 72 19.872

Total 1946.895 74

RESULTS

36

Table 3 : Post hoc comparison of three groups : clinical, OPG, CBCT

Post Hoc Tests

Multiple Comparisons

Tukey HSD

Dependent Variable

Mean

Difference (I-J)

Std. Error

Sig.

95% Confidence Interval

(I) GROUP (J) GROUP Lower Bound

Upper Bound

LEFT HCI CLINICAL METHOD OPG

CBCT

-6.1600 *

-1.3320

1.2163

1.2163

.000

.520

-9.071

-4.243

-3.249

1.579

OPG CLINICAL METHOD

CBCT

6.1600*

4.8280*

1.2163

1.2163

.000

.000

3.249

1.917

9.071

7.739

CBCT CLINICAL METHOD

OPG

1.3320

-4.8280 *

1.2163

1.2163

.520

.000

-1.579

-7.739

4.243

-1.917

RIGHT HCI CLINICAL METHOD OPG

CBCT

-6.0560 *

-1.1680

1.2609

1.2609

.000

.626

-9.073

-4.185

-3.039

1.849

OPG CLINICAL METHOD

CBCT

6.0560*

4.8880*

1.2609

1.2609

.000

.001

3.039

1.871

9.073

7.905

CBCT CLINICAL METHOD

OPG

1.1680

-4.8880 *

1.2609

1.2609

.626

.001

-1.849

-7.905

4.185

-1.871

*. The mean difference is significant at the .05 level.

RESULTS

37

Table 4: Mean value of three groups subjected to correlation test for left side.

Correlations LEFT HCI

Descriptive Statistics

Table 5 : Pearson correlation test to determine the correlation between three

groups on the left side

Correlations

CLINICAL

METHOD

OPG

CBCT

CLINICAL METHOD Pearson Correlation 1 .970 ** .979 **

Sig. (2-tailed) .000 .000

N 25 25 25

OPG Pearson Correlation .970** 1 .941 **

Sig. (2-tailed) .000 .000

N 25 25 25

CBCT Pearson Correlation .979** .941 ** 1

Sig. (2-tailed) .000 .000

N 25 25 25

**. Correlation is significant at the 0.01 level (2-tailed).

Mean Std. Deviation N

CLINICAL METHOD 29.8000 4.44410 25

OPG 35.9600 4.23094 25

CBCT 31.1320 4.22204 25

38

RESULTS

Table 6 : Mean value of three groups subjected to correlation test for right side

Correlations RIGHTHCI

Descriptive Statistics

Mean Std. Deviation N

CLINICAL METHOD 29.8000 4.44410 25

OPG 35.8560 4.21071 25

CBCT 30.9680 4.70494 25

Table 7 :Pearson correlation test to determine the correlation between three groups

on the right side.

Correlations

CLINICAL

METHOD

OPG

CBCT

CLINICAL METHOD Pearson Correlation 1 .970 ** .958 **

Sig. (2-tailed) .000 .000

N 25 25 25

OPG Pearson Correlation .970** 1 .947 **

Sig. (2-tailed) .000 .000

N 25 25 25

CBCT Pearson Correlation .958** .947 ** 1

Sig. (2-tailed) .000 .000

N 25 25 25

**. Correlation is significant at the 0.01 level (2-tailed).

39

RESULTS

Diagram 1: Bar diagram indicating comparisons of right and left HCI for three

groups

Comparisons of right and left HCI (in degrees) for the different methods

45

40

35

30

25

20

15

10

5

0

PROTRUSIVE METHOD PANORAMIC

RADIOGRAPH

CBCT

LEFT HCI RIGHT HCI

MEA

N ±

SD

40

Discussion

DISCUSSION

40

The study aimed to find the horizontal condylar inclination in dentulous subjects

using clinical and two radiographic techniques namely OPG and CBCT method.

The null hypothesis was partially rejected, as significant difference existed

between clinical and OPG method and also between radiographic techniques i.e., OPG

and CBCT as well. Reason for partial rejection is that no significant difference existed

between clinical and CBCT method.

The present study dictates that the mean value of horizontal condylar inclination

found using clinical method on the left and right side of the 25 dentulous subjects is

29.800, ranging from 20.0 minimum to 35.0 maximum.

Literature23

suggests that the horizontal condylar inclination values may range

from 8 to 54. Horizontal condylar inclination values varies with age, gender and

ethnicity. The current study was conducted in a chosen population following the

inclusion & exclusion criteria.

In the clinical method, HCI measurements were repeated thrice with 3 different

inter-occlusal records for each individual to lessen the possibility of operator error. Most

probably, the measurements were same on all the three occasions. On the contrary to our

study, Craddock et al30

took 3 separate wax records on each patient and found the

values to be different on each occasion. Reason behind that variation is the amount of

protrusion done by the patient. The amount of protrusion is not standardized and varied

on each occasion. Whereas, in the present study, subjects were asked to move forward

the mandible to edge to edge protrusion and it has been standardized in all the

individuals.

DISCUSSION

41

Alu wax was chosen as material of choice to obtain protrusive inter-occlusal

record. In accordance to the study conducted by Curtis DA et al11

, recording material

alters the HCI values of the patient. He believed that Alu wax was better than the

polyvinyl siloxane registration material. Because of the resilient nature of the polyvinyl

siloxane bite registration material, it is bound to give higher HCI values.

Hanua Wide-vue semi adjustable articulator was used to measure horizontal

condylar inclination, once the protrusive inter-occlusal record is obtained. Hanua

articulator provides more accurate angle since it mounts the cast in reference to Frankfort

horizontal plane, as suggested by Dos Santos et al31

& Olsson and Posselt32

. They

believed that reference plane has a role to play in measuring horizontal condylar

inclination. Values measured by whip mix, quick set recorder which uses nasion-porion

as a reference plane, were higher compared to Hanua articulator which uses Frankfort

horizontal plane. Hanua Wide Vue articulator is the most ideal semi-adjustable

articulator to measure horizontal condylar inclination.

In the present study, Mean value of left HCI measured on 25 subjects following

OPG method is 35.960, ranging from 26.4 minimum to 41.8 maximum.Mean value of

right HCI measured on 25 subjects using OPG method is 35.856, ranging from 26.8

minimum to 43.5 maximum.

HCI values obtained using panoramic radiograph method is 6 -7 degrees higher

than the values obtained using clinical method. Results obtained were well supported by

the literature10,11,12,13,14,15

. Responsible factor for such discrepancy is the overlapping of

radiopaque structures in the field of concern and difficulty in interpreting the anatomical

landmark exactly such as the inferior most point on the articular eminence.

DISCUSSION

42

Demarcation of the inferior most point on the articular eminence is difficult as it

is overlapped by the inferior border of the zygomatic arch, as suggested by Gilboa I et

al14

. He explained it well by adapting two orthodontic wires along the border of articular

eminence and the inferior border of zygomatic arch of the dried human skulls , thereby

establishing the discrepancies arising out of it.

To overcome this discrepancy, digital panoramic imaging was used in our study.

In digital OPG, density can be adjusted using the software to differentiate the inferior

border of zygomatic arch and the inferior most point on the articular eminence. As

suggested by Davis and Mackay33

, Digital imaging compared to conventional

radiographic films provided high resolution images, ease of analysis, less time

consuming and thereby low radiation exposure.

Moreover, HCI measurement using software eradicated the possibility of human

error, removed the tracing procedure mostly leading to wrong measurements, removes

the chance of problems arising due to manual error in the film processing / developing.

Mean value of left HCI measured on 25 subjects following CBCT method is

31.132, ranging from 21.7 minimum to 36.2 maximum.. Mean value of right HCI

measured on 25 subjects using CBCT method is 30.968, ranging from 21.2 minimum to

36.9 maximum.

In the CBCT method, images were reconstructed using the software ( NNT

viewer ). 0.5 mm thick cross sectional slices were prepared and mid-sagittal plane

passing through the exact centre of the condyle is chosen for examination. The particular

slice is selected for HCI measurement, as suggested by Sümbüllü MA6, because that

DISCUSSION

43

gives the steepest part of eminence and accurate measurement of horizontal condylar

inclination.

Initially CT scans were used to measure HCI measurement as suggested by

Shreshta P et al8. but later its use in dentistry is diminished with the advent of CBCT.

Since it overcomes the drawbacks of CT scan such as radiation exposure, expense and

multiple slices.

Reference planes used in the present study were chosen according to the evidence

supported by Sümbüllü MA6. He used two planes to measure horizontal condylar

inclination in the same individual using CBCT. Two planes used were best-fit plane and

top-roof plane. HCI was measured by measuring the angle formed between the Frankfort

horizontal plane and either of these two planes in their respective groups. Results

revealed that best-fit plane provided higher angles which is clinically irrelevant. The top

roof plane provided accurate values and it is clinically significant. Hence the top roof

plane was used in our study i.e., the line connecting the superior most point on the

glenoid fossa and the inferior most point on the articular eminence.

Sümbüllü MA6 measured the HCI values in patients under three age groups:

Group 1 :16-20 years of age, Group 2 : 21-30 years of age, Group 3 : 31-40 years of age.

Whereas in the present study, measurements were made only in patients with age group

of 18-30 years of age. In contrast to Sümbüllü MA6 study, where only CBCT

measurements were done, CBCT measurements were compared against the clinical and

panoramic radiograph method to check its reliability.

Similar to the present study, CBCT measurements of horizontal condylar

inclination were compared against the protrusive inter-occlusal record method and

DISCUSSION

44

panoramic radiograph method. CBCT values were found to be 5-6 higher than clinical

method. Contradictory to the present study, where CBCT measurements were as close to

clinical method and found to be only 1-2 degree higher. The possible explanation might

be difference in the machine used and the DICOM software used for analysis. It can also

be attributed to subjective error.

CBCT scans were taken separately for left and right side of the patient. As a

result, two TMJ views were taken for each individual involved in the study. Considering

the other two methods, HCI measurements of the left and right side were done in the

same inter-occlusal record in case of clinical method and in the same panoramic image in

case of OPG method, where both TMJ will be covered in the single panoramic image.

Researchers believed that variation in HCI values will be seen between the left

and right side of the patient. Variation may range up to 22 degrees. To analyse the

existence of variation between the left and right side of the subject, both HCI

measurements were done in our study. But to the contrary, study reveals no significant

difference between the left and right HCI values. Reason might be the sample size of the

population involved and the constrained inclusion and exclusion criteria.

Pearson correlation test was conducted to test the correlation between the three

groups involved.Pearson correlation test revealed that significant correlation existed

between three groups in both left and right side ( P = 0.000) as expressed in table 5 & 7.

In addition to pearson correlation test suggesting significant correlation between

clinical and CBCT method, Post hoc intergroup comparison suggesting no significant

difference between clinical and CBCT method gives a clear cut idea that HCI values

DISCUSSION

45

measured using CBCT method were close to clinical method and as accurate as clinical

method.

Hence to conclude, CBCT method is as reliable as clinical method compared to

other radiographic technique i.e., panoramic radiograph.

47

Summary

SUMMARY

46

Longevity of the prosthesis and its occlusal harmony with patient’s

neuromuscular system depends on horizontal condylar inclination of the patient. Average

condylar settings were followed for the fabrication of prosthesis, but the occlusal

harmony cannot be achieved since it does’nt match patient’s own horizontal condylar

inclination. Horizontal condylar inclination can be determined by various methods such

as protrusive interocclusal record method, graphic tracing method, jaw motion analyzer

and electronic pantograph. CBCT can be a useful tool in measuring horizontal condylar

inclination. The aim of the study is to evaluate the horizontal condylar inclination in

dentulous subjects using clinical and two radiographic techniques namely OPG and

CBCT and to assess the reliability of clinical over radiographic methods.

HCI measurements of twenty five healthy dentulous subjects were measured

using clinical method, OPG method and CBCT method. In the clinical method, HCI is

measured using Hanua wide-vue semi-adjustable articulator with the help of protrusive

wax record obtained at the level of edge to edge protrusion. In OPG and CBCT method,

digital images were analysed using the software to determine HCI values. HCI values

were measured on both left and right side of the subjects under each group.

Mean value of left HCI measured on 25 subjects following Clinical method, OPG

method, CBCT method were 29.800, 35.960, 31.132 respectively. Mean value of right

HCI measured on 25 subjects following clinical, OPG and CBCT method were 29.800,

35.856, 30.968 respectively.

Statistical tests revealed that significant difference found between clinical and

OPG method and between OPG and CBCT as well. Between clinical and CBCT method,

SUMMARY

47

Significant difference was not found. Correlation test showed significant correlation

between three groups.Results revealed that CBCT values were closer to clinical method

and it is as reliable as clinical method. OPG method showed 5-6 degrees higher values

than clinical and CBCT method.

Conclusion

CONCLUSION

48

• Horizontal condylar inclination can be accurately measured by means of

clinical method and by CBCT .

• CBCT method is as reliable and as accurate as clinical method

• Significant correlation exists between clinical and CBCT

• Between radiographic techniques , OPG showed higher HCI values than

CBCT

• CBCT can be used as a reliable adjunct to clinical method of HCI

measurement.

52

Bibliography

BIBLIOGRAPHY

49

1. Posselt U, Nevstedt P. Registration of the condyle path inclination by intraoral

wax records—its practical value. Journal of Prosthetic Dentistry. 1961 Jan

1;11(1):43-7.

2. GERBER, A. & STEINHARDT, G. (1990) Dental Occlusion and the

Temporomandibular Joint, p, 13. Quintessence Publishing Co Inc. Chicago, USA

3. LAMB, D.J. (1993) Problems and Solutions in Complete Denture Prosthodontics,

p. 160. Quintessence Publishing Co Inc. Chicago, USA.

4. dos Santos Jr J, Nelson S, Nowlin T. Comparison of condylar guidance setting

obtained from a wax record versus an extraoral tracing: a pilot study. The Journal

of prosthetic dentistry. 2003 Jan 1;89(1):54-9.

5. Christensen LV, Slabbert JC. The concept of the sagittal condylar guidance:

biological fact or fallacy?. Journal of oral rehabilitation. 1978 Jan;5(1):1-7.

6. Sümbüllü MA, Cağlayan F, Akgül HM, Yilmaz AB. Radiological examination of

the articular eminence morphology using cone beam CT. Dentomaxillofacial

Radiology. 2012 Mar;41(3):234-40.

7. Kwon OK, Yang SW, Kim JH. Correlation between sagittal condylar guidance

angles obtained using radiographic and protrusive occlusal record methods. The

journal of advanced prosthodontics. 2017 Aug 1;9(4):302-7.

8. Shreshta P, Jain V, Bhalla A, Pruthi G. A comparative study to measure the

condylar guidance by the radiographic and clinical methods. The journal of

advanced prosthodontics. 2012 Aug 1;4(3):153-7.

9. Veloso L, Dias R, Messias A, Fonseca J, Nicolau P. Evaluation of condylar

position by CBCT after static and dynamic registration in edentulous patients.

BIBLIOGRAPHY

50

Revista Portuguesa de Estomatologia, MedicinaDentária e CirurgiaMaxilofacial.

2015 Jan 1;56(1):9-17.

10. Tannamala PK, Pulagam M, Pottem SR, Swapna B. Condylar guidance:

correlation between protrusive interocclusal record and panoramic radiographic

image: a pilot study. Journal of Prosthodontics. 2012 Apr 1;21(3):181-4.

11. Galagali G, Kalekhan SM, Nidawani P, Naik J, Behera S. Comparative analysis

of sagittal condylar guidance by protrusive interocclusal records with panoramic

and lateral cephalogram radiographs in dentulous population: A clinico-

radiographic study. The Journal of the Indian Prosthodontic Society. 2016

Apr;16(2):148.

12. Paul R, Das S, Bhattacharyya J, Ghosh S, Goel P, Dutta K. A study on the

accuracy of horizontal condylar guidance values in edentulous patients using

preprosthetic diagnostic radiographs. The Journal of Indian Prosthodontic

Society. 2018 Jul 1;18(3):263.

13. Prasad KD, Shah N, Hegde C. A clinico-radiographic analysis of sagittal

condylar guidance determined by protrusive interocclusal registration and

panoramic radiographic images in humans. Contemporary clinical dentistry. 2012

Oct;3(4):383.

14. Gilboa I, Cardash HS, Kaffe I, Gross MD. Condylar guidance: correlation

between articular morphology and panoramic radiographic images in dry human

skulls. The Journal of prosthetic dentistry. 2008 Jun 1;99(6):477-82.

15. Kaur S, Datta K. An in vitro study to evaluate the accuracy of

orthopantomograph as an aid to determine condylar guidance. The Journal of

Indian Prosthodontic Society. 2018 Jan 1;18(1):35.

BIBLIOGRAPHY

51

16. Curtis DA. A comparison of protrusive interocclusal records to pantographic

tracings. Journal of Prosthetic Dentistry. 1989 Aug 1;62(2):154-6.

17. Ratzmann A, Mundt T, Schwahn C, Langforth G, Hutzen D, Gedrange T,

Kordass B. Comparative clinical investigation of horizontal condylar inclination

using the JMA electronic recording system and a protrusive wax record for

setting articulators. International journal of computerized dentistry. 2007

Jul;10(3):265-84.

18. Pelletier LB, Campbell SD. Comparison of condylar control settings using three

methods: a bench study. Journal of Prosthetic Dentistry. 1991 Aug 1;66(2):193-

200.

19. Preti G, Scotti R, Bruscagin C, Carossa S. A clinical study of graphic registration

of the condylar path inclination. Journal of Prosthetic Dentistry. 1982 Oct

1;48(4):461-6.

20. Posselt U, Skytting B. Registration of the condyle path inclination: variations

using the Gysi technique. Journal of Prosthetic Dentistry. 1960 Mar 1;10(2):243-

7.

21. El-Gheriani AS, Winstanley RB. Graphic tracings of condylar paths and

measurements of condylar angles. Journal of Prosthetic Dentistry. 1989 Jan

1;61(1):77-87.

22. Celar AG, Tamaki K. Accuracy of recording horizontal condylar inclination and

Bennett angle with the Cadiax compact®. Journal of oral rehabilitation. 2002

Nov;29(11):1076-81.

23. Johnson A, Winstanley RB. Recording sagittal condylar angles using a

mandibular facebow. Journal of oral rehabilitation. 1997 Dec;24(12):904-8.

BIBLIOGRAPHY

52

24. Prasad KD, Shetty M, Chandy BK. Evaluation of condylar inclination of

dentulous subjects determined by axiograph and to compare with manual

programming of articulators using protrusive interocclusal record. Contemporary

clinical dentistry. 2015 Jul;6(3):371.

25. Chang WS, Romberg E, Driscoll CF, Tabacco MJ. An in vitro evaluation of the

reliability and validity of an electronic pantograph by testing with five different

articulators. The Journal of prosthetic dentistry. 2004 Jul 1;92(1):83-9.

26. Prajapati P, Sethuraman R, Naveen YG, Patel J. A clinical study of the variation

in horizontal condylar guidance obtained by using three anterior points of

reference and two different articulator systems. Contemporary clinical dentistry.

2013 Apr;4(2):162.

27. Gross M, Nemcovsky C, Tabibian Y, Gazit E. The effect of three different

recording materials on the reproducibility of condylar guidance registrations in

three semi-adjustable articulators. Journal of oral rehabilitation. 1998

Mar;25(3):204-8.

28. Goyal MK, Goyal S. A comparative study to evaluate the discrepancy in condylar

guidance values between two commercially available arcon and non-arcon

articulators: A clinical study. Indian Journal of Dental Research. 2011 Nov

1;22(6):880.

29. Sreelal T, Janardanan K, Nair AS, Nair AS. Age changes in horizontal condylar

angle: A clinical and cephalometric study. The Journal of Indian Prosthodontic

Society. 2013 Jun 1;13(2):108-12.

BIBLIOGRAPHY

53

30. Craddock FW. The accuracy and practical value of records of condyle path

inclination. The Journal of the American Dental Association. 1949 Jun

1;38(6):697-710.

31. Santos JD, J. Nelson S, Nummikoski P. Geometric analysis of occlusal plane

orientation using simulated ear‐rod facebow transfer. Journal of Prosthodontics.

1996 Sep;5(3):172-81.

32. Olsson A, Posselt U. Relationship of various skull reference lines. Journal of

Prosthetic Dentistry. 1961 Nov 1;11(6):1045-9.

33. Davis DN, Mackay F. Reliability of cephalometric analysis using manual and

interactive computer methods. British journal of orthodontics. 1991 May

1;18(2):105-9.

U R K U N D

Urkund Analysis Result

Analysed Document: Thesis final

report.docx (D46664786) Submitted: 1/11/2019

11:04:00 AM

Submitted By: [email protected]

Significance: 3 %

Sources included in the report:

https://www.researchgate.net/

publication/6472734_The_horizontal_condylar_inclination_Clinical_comparison_

of_different_rec ording_methods

https://synapse.koreamed.org/Synapse/Data/PDFData/0170JAP/jap-4-153.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549989/

http://www.j-ips.org/article.asp?

issn=0972-

4052;year=2018;volume=18;issue=3;spage=263;epage=270;aulast=Pau

l

Instances where selected sources appear:

4

mailto:[email protected]

http://www.researchgate.net/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549989/

http://www.j-ips.org/article.asp

A STUDY TO EVALUATE THE HORIZONTAL CONDYLAR … · 2019. 8. 15. · condylar path is the path traveled by the mandibularcondyle in the temperomandibular joint during various mandibularmovements

Documents