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 Table of Contents  
SYSTEMATIC REVIEW
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 121-135

Uses, accuracy and limitations of semiadjustable articulators in dentistry: a systematic review


1 Department of Prosthodontics, Rajarajeswari Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Prosthodontics, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Date of Submission27-Jan-2019
Date of Acceptance03-Apr-2019
Date of Web Publication14-Jan-2020

Correspondence Address:
Ramesh Chowdhary
Department of Prosthodontics, Rajarajeswari Dental College and Hospital, Bangalore 560 074, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_8_19

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  Abstract 

Purpose: The article reviewed the various studies on semiadjustable articulators (SAA) to determine their uses, accuracy and limitations in orienting the cast.
Materials and methods: An electronic and manual search of PubMed and Medline databases and other published articles was performed. The article concomitant to question in focus on accuracy of cast orientation on to the SAA with the help of facebow when compared to the lateral cephalogram was included. Other question in focus was whether interocclusal records used for programming the articulator are more accurate than the computerized jaw-tracking devices. Article on reliability, repeatability and interchangeability of SAA were also included. The study also focused on the use of SAA in various specialties of dentistry with the help of available literatures. Only articles in English were considered for the study.
Results: The initial search resulted in 450 papers. The reviewers independently screened the abstracts for those articles related to the focus question. Of the resulted 72 studies, 16 were excluded for not being in English, resulting in 56 entries. Hand-searching yielded 2 additional papers.
Conclusion: SAA seems reliable in interchangeability and promising to be used in various fields of dentistry. The condylar guidance obtained by SAA proves to be more accurate than other radiographic methods. Jaw motion analyzer is more accurate in adjusting the SAA rather than protrusive records.

Keywords: articulator, bennett angle, lateral cephalogram, orthognathic surgeries, prosthodontics, semiadjustable articulator


How to cite this article:
Sutradhar W, Mishra SK, Chowdhary R. Uses, accuracy and limitations of semiadjustable articulators in dentistry: a systematic review. Tanta Dent J 2019;16:121-35

How to cite this URL:
Sutradhar W, Mishra SK, Chowdhary R. Uses, accuracy and limitations of semiadjustable articulators in dentistry: a systematic review. Tanta Dent J [serial online] 2019 [cited 2020 Feb 17];16:121-35. Available from: http://www.tmj.eg.net/text.asp?2019/16/3/121/275937


  Introduction Top


An articulator is a mechanical instrument that represents the temporomandibular joints (TMJ) and jaws, to which maxillary and mandibular casts may be attached to simulate some or all mandibular movements [1]. Articulators help in diagnosis and treatment planning by studying the teeth and dental arches. An articulator is used in different branches of dentistry by assisting in processing of fixed and removable appliances [2].

In history of articulators, the articulators were introduced by Phillip Pfaff with Plaster Articulator in 1756[3],[4]. Later Barn Door Hinge, articulator with a heavy-duty hinge was introduced followed by Kerr articulator with fixed protrusive and lateral movement [3–6]. In 1921 Rudolph L. Hanau introduced the Hanau Model C, later in 1923 Hanau model M Kinoscope Articulator came with double condylar post having varying rotation centers[7],[8]. Joseph Homer introduced an articulator with plastic guides to preserve the position of articulator called as the Homer Relator [9]. In 1922 and 1923, Hanau Model H110 articulator was introduced for the dental profession to overcome the more sophisticated kinoscope instrument [7].

The orientation of maxillary cast on the articulator is the main criteria for recording perfect occlusal relationships. Maxillary cast is positioned on articulator with the support of three reference points; one located anteriors and two other posterior to maxilla [10]. The accuracy of articulator is determined as how exactly it accepts the facebow transfer of maxillary cast on to the articulator and simulate occlusal plane (OP) to the opening axis of articulator in a similar position as it is in the patients' skull. The articulator is considered to be accurate when it relates the plane of occlusion transferred through facebow to the opening axis of the articulator in the similar way as it is present in the mouth when the Frankfort horizontal plane (FHP) is parallel to the floor [11]. Correct registration of centric and eccentric records also contributes to program the articulator and determine the Condylar Guidance angle (CGA), to determine the occlusal relationship and occlusal errors. These angles are relative measure, which is related to the angle of e eminence of the TMJ [12].

Radiographs were used by clinicians to determine CGA of the patients to programme the articulator instead of facebow transfer. They determine the angle formed in between the FHP and OP on the radiograph and use this value to programme the articulator [13]. Currently clinician also take the help of virtual articulators in restorative and prosthetic dentistry, and in digital surgical procedures [14]. Virtual articulator produces digital three-dimensional (3D) representations of the jaws movements [15].

Semiadjustable articulator (SAA) is defined as an instrument that simulates condylar pathways by using averages or mechanical equivalents for all or part of the motion; these instruments allow for orientation of the casts relative to the joints [1]. SAA is one, which is adjustable in one or more, but not all of the following areas: condylar angle, lateral movement of condyle, incisal and cuspid guidance, and shape of the glenoid fossae and eminintiae. Use of SAA is only meaningful if the positions of the maxillae are duplicated, with respect to the position of the mandibular condyles. The majority of these articulators again have straight condylar paths, the path angle may be changed, allowing the patient's condylar angle to be programmed into the articulator. This mimics the movement of the condyles better than some ball-shaped condylar heads found on other articulators. Normally this is achieved by the use of a facebow [16]. With the evolution of materials, researches and technology, SAA is used increasingly in modern dentistry [17].

As SAA is commonly available and used but its reliability when compared to other modalities such as radiographic data and virtual articulators is still not fully known and understood. This review aims to find out their uses in different specialities of dentistry, and also to find accuracy of the records transferred on these articulators, when compared to radiographic data and virtual articulators.


  Materials and Methods Top


Search strategies

A structured systematic search without any time or language restrictions was done in October 2018 in the Medline/PubMed database. The following search terms were used, with the filter 'article types' selected with the item 'abstract':

{Subject AND Adjective}

{Subject: (articulator OR semi-adjustable articulator) AND

Adjective: (uses OR limitations OR accuracy OR prosthodontics OR orthodontics OR oral surgery OR pedodontics OR periodontics OR oral diagnosis)}

The reference list of the identified studies and the relevant reviews on the subject were also screened for possible additional studies.

Focused questions

The uses, accuracy and limitations of SAA were evaluated with the help of following focused questions in this systematic review.

  1. How accurately is the occlusal cant on radiograph is reproduced by the SAA in programming saggital condylar inclination (SCI)?
  2. Whether Hanau SAA is more accurate than other SAA?
  3. Whether interocclusal records used for programming the SAA are more accurate than the computerized jaw-tracking devices?
  4. Whether SAA reproduces the anterior guidance more accurately?
  5. How much reliable and repeatable are the interchangeability of the SAA?
  6. The study also focused on the uses of SAA in various specialties of dentistry with the help of available literatures.


Inclusion and exclusion criteria

Eligibility criteria included randomized or nonrandomized clinical trials, case series and comparative studies using SAA. Surveys and review articles were excluded. Articles not in English were excluded.

Study selection

The abstracts and titles of all articles obtained through electronic search were independently read by three reviewers and any disagreement arise among them regarding the selected articles was resolved by a discussion between them.

Data extraction

Following data were obtained from the studies included in the study: author, year of publication, study design, types of SAA, uses, conditions where SAA were used, gold standard, performance and accuracy of articulators.


  Results Top


The process of article selected for study is summarized in [Figure 1]. A total of 450 papers were obtained related to focus questions from search strategy. Each reviewer screened independently the abstracts and then selected 72 articles out of it. 16 articles not being in English were excluded further, and resulted in 56 articles. Hand-search of three main prosthodontics journals: Journal of Prosthetic Dentistry, Journal of Prosthodontics, and International Journal of Prosthodontics and further cross-referencing of the selected articles resulted in two additional papers. Final inclusion resulted in 58 articles in this systematic review.
Figure 1: Flow chart presented the screening of articles related to the uses, accuracy, limitations and comparison of semiadjustables articulators to be included in this review.

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Comprehensive data of 58 studies included are listed in Tables as, 20 articles on uses and importance of SAA in [Table 1] [18–37] and 38 articles on accuracy and limitations of SAA in [Table 2][12],[15],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73].
Table 1 Studies on the uses and importance of semiadjustable articulators

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Table 2 Studies on accuracy and limitations of semiadjustable articulators

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  Discussion Top


The focused questions on uses, accuracy and limitations of the SAA in this article were answered with the help of the selected literature in this systematic review.

How accurately is the occlusal cant on radiograph is reproduced by the semiadjustable articulators in programming the saggital condylar inclination?

Lateral cephalogram is considered as gold standard as it is an important tool to identify the relationships between the teeth and other cranial landmarks which are not subjected to postextraction changes. The accuracy of articulators can be assessed by comparing the Occlusal cant (angle formed by the FHP-OP) on the lateral cephalogram with the orientation of the OP of maxillary cast on to the articulator through facebow transfer [13]. Occlusal cant should be almost same as in patients, when OP is transferred on to the articulator. During positioning of maxillary cast on to the articulator, if the correct maxillary-mandiular relationship is not transferred and correlated to the opening and closing movements in the articulator, an error in occlusion results. There will be interceptive and deflective tooth contacts which can lead to TMJ pain, muscle spasm, and periodontal problems [38].

SCI (also called as horizontal condylar inclination) is the angle formed by the path of the moving condyles within the sagittal plane compared with the horizontal plane (anterior–posterior movement) [1]. In a study by Galagali et al. [53], SCI obtained on SAA with lateral cephalogram radiograph tracings and with interocclusal records were measured. The mean difference between the condylar guidance values obtained with the radiographic values being slightly higher. Similar result was obtained by Shrestha et al.[50] with computed tomographic scan showed higher HCG values than the clinical methods. Shetty and colleagues[38],[57] also found higher condylar guidance values from the radiograph when evaluated the reliability of programming the articulator using the radiographs and the interocclusal records.

In various studies[48],[52],[53] the angle of steering axis inclination obtained on a SAA and the corresponding angle traced on a TMJ radiograph showed significant correlation. Articular eminence traced on a TMJ tomogram image represents the SCI with a mean difference of 5° [48]. Similar results obtained by Tannamala et al.[12] with a mean difference of 4°. Sreelal et al.[49] in their study found that both cephalometric and articulator method can be used in determining condylar inclination. Godavarthi et al.[56] correlated condylar guidance obtained by panoramic radiographs with conventional methods in dentulous and edentulous patients and found that only in edentulous patients, panoramic radiograph can be used as an alternative to interocclusal technique.

Whether Hanau SAA is more accurate than other SAA?

The SCI of mounted maxillary casts with Hanau articulator was closer to the occlusal cant recorded with cephalometric method [54]. The accuracy of transfer of the maxillary occlusal cant on to the articulator seems to be more accurate with Hanau wide-vue articulator than that of Artex Amann Girrbach articulator [38]. The Hanau wide-vue articulator showed closer values to that of the cephalometric values in reproducing OP compared to the Whip Mix articulator system [41].

Whether interocclusal records used for programming the semiadjustable articulators are more accurate than the computerized jaw-tracking devices?

The Hanau wide-vue articulator has showed more accurate results in the 3D condylar shift facebow transfer as compared to the average mounting in the same articulator [71]. Hanau articulator has been used to show the simulation of dental collisions and occlusal dynamics in the virtual environment. More accurate measurements of the SCI were obtained by Hanau condyle repositioner, and Hanau H2O, Denar cadiax compact, when assessed by a jaw-tracking system [55]. In another study by Ratzmann et al.[51] were they used SAM 2 and Reference SL articulator to compare the horizontal condylar inclination obtained with Jaw motion analyzer, found pantographic device is more accurate and should be considered for adjusting the articulators rather than protrusive records.

Lateral condylar inclination is the angle formed by the path of the moving condyle within the horizontal plane compared with the median plane (anterior–posterior movement) and within the frontal plane when compared with the horizontal plane (superior–inferior movement) [1]. Bhawsar et al.[61] did a study to compare lateral condylar guidance values using the Hanau's formula from protrusive records and also using the computerized K7 jaw-tracking device. lateral condylar guidance values obtained using the Hanau's formula ranged from 14° to 17° and with computerized K7 jaw-tracking device ranged from 8° to 40°. Dentist and dental technicians should reassess the recommended average settings and Hanau's formula for programming the SAA.

Whether semiadjustable articulators reproduces the anterior guidance more accurately?

Anterior guidance is the influence of the contacting surfaces of the guide pin and anterior guide table on articulator movements. Anterior guidance is also the influence of the contacting surfaces of anterior teeth, limiting mandibular movements [1]. Studies on SAA prove that unilateral chewing creates uneven wear on the anterior teeth and changed the anterior guidance angulation [60]. SAA reproduces the movements more accurately due to constant relation between OP and mechanical fossa and provides more accurate results [59].

How much reliable and repeatable are the interchangeability of the semiadjustable articulators?

Clinician usually use one type of articulator and send casts to a dental laboratory for fabrication of restorations, with the assurance that the casts will be remounted in the same positional accuracy on a similar type of articulator. Interchangeability of a SAA in between clinics and laboratory could be of significantly convenient and economically beneficial to the restorative dentist [46]. The question arises in such situations is, how much reliable and repeatable is the interchangeability of articulators. Hatzi et al.[69] in their study found that Artex articulator provided the most consistent repeatability and interchangeability followed by Kavo and Whip Mix. Price et al.[68] found that new, unused Whip Mix model #2240 and #3040 articulators are potentially interchangeable in the centric position. Whip Mix model #2240 articulator can remain interchangeable during clinical use for 7 years and should be regularly calibrated [73]. Laboratory procedures which involve multiple restorations can be done accurately when master casts are mounted and transferred in between Hanau modular articulators [46]. Hanau articulator can produce an occlusal error of 0.2 mm from interchanging of dental casts on the articulator system that a clinician should know [70].

Uses of semiadjustable articulators in various specialities of dentistry

The SAA has been used in the fabrication of palatal ramp prosthesis in a partially resected mandible with reduced chairside time and improved patient comfort [20]. It has also been used in the prosthetic rehabilitation of patients with temporomandibular dysfunction (TMD) [21]. SAA have been used to determine the OP using a custom made broadrick OP analyzer[28],[44]. It has been used in studying the effects of equilibrating mounted dental stone casts on the occlusal harmony of cast metal complete crowns. A cast adjustment procedure can aid in fabrication of a crown with a more accurate occlusion [24]. They have been used for computer aided design of complete denture which explored a virtual SAA program for complete denture CAD system. With the program, 3D biting motion simulating, automatic occluding relation detection and automatic occlusal adjustment can be realized [26].

SAA have been used to derive the implant loading forces as influenced by occlusal anatomy and it was found that implant loading can be reduced by modifying the location of the impact area and the occlusal anatomy. Simple modification of the incisal pin and articulator settings can be used to produce 1.5-mm flat fossae, which results in more vertical forces to the supporting bone [30]. The SAA has been used in planning for maxillary impactions for orthognathic surgery and used for reproduction of OP[35],[36].

In endodontics, the SAA was used to study the correlation of noncarious cervical lesions and occlusal wear and it was found that no relation was present between noncarious cervical lesions and occlusal–incisal wear [37].

In orthodontics studies have been done to find the need for SAA and it was found that many stages involve in mounting study models on a SAA is a potential source of error and that only if the technique is carried out with a high degree of accuracy is it worth the additional chairside time. In case of mandibular midline distraction osteogenesis SAA can provides postexpansion relationship of the maxillary and mandibular arches and thus provide useful information to the surgeon and orthodontist [34]. SAA helps in study the occlusal features of orthodontically treated patients and is useful in follow up of orthodontic patients to study occlusal discrepancies[33],[64]. Centric relation-maximum intercuspation discrepancy found in most of the pretreated orthodontic patients with signs and symptoms of TMD and this discrepancy may act as a contributory factor to the development of TMD in these patients [63].

SAA were the most popular for planning orthognathic surgery. Interim splint, constructed from sectioned models mounted on a SAA helps in orthognathic surgeries [36]. In case of model surgery and operation if there is any error during transfer of cast on articulator it results in discrepancies in surgery [35]. Different facebow/articulator systems could result in different orientation of the maxillary cast, resulting in variation in stability, cuspal inclines and cuspal heights [54]. Each occlusal adjustment procedure in the mouth should be preceded by an initial study, occlusal analysis and occlusal adjustment on articulator mounted casts. Cast adjustments should be done on semiadjustable articulator before fabricating prosthesis as it significantly decreases the time for lengthy clinical occlusal adjustment [66].


  Conclusion Top


SAA seems reliable in interchangeability and promising to be used in various fields of dentistry ranging from prosthodontics to orthognathic surgeries with accurate results. Hanau wide-vue articulator seems to be more accurate in reading of the FHP-OP angle of the casts as compared to other articulators. The condylar guidance obtained by SAA proves to be more accurate than other radiographic methods. Jaw motion analyzer is more accurate in adjusting the SAA rather than protrusive records. Further research and improvement in SAA is required to provide accurate results with interocclusal records to meet the accuracy provided with jaw motion analyzers.

Acknowledgments

None.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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