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J Stomatol Oral Maxillofac Surg 000 (2021) 1−8

Available online at

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www.sciencedirect.com

Review

Methods of mandibular condyle position and rotation center used

for orthognathic surgery planning: a systematic review

Barretto MDA, Maxillofacial Surgeon, PhD’s Degree Student*,

Melhem-Elias F, Maxillofacial Surgeon. PhD, Associate Professor,
Deboni MCZ, PhD, Associate Professor
Department of Oral and Maxillofacial Surgery, Prosthesis and Traumatology, School of Dentistry, University of Sao Paulo, Av. Lineu Prestes, 2227, 05088-000 Sao
Paulo, SP, Brazil

A R T I C L E I N F O A B S T R A C T

Article History: We aimed to evaluate whether there is a consensus among bi- (2D) and three-dimensional (3D) evaluations
Received 27 May 2021 of mandible condyle position and its rotation center. Also, if this data can be replicated in orthognathic sur-
Accepted 11 June 2021 gery planning. The survey was carried out on the major databases (PubMed, SCOPUS, Embase, Cochrane).
Available online xxx
Human or human bio models evaluations in 2D or 3D of mandibular condylar position concerning its fossa
and rotational axis for orthognathic surgery planning were eligible. The heterogeneity of the studies and
Keywords:
uncertainties in methodological biases did not allow us to identify the superiority of 2D or 3D methodology
Review
in determination of the condylar rotational axis. There is a lot of divergences in the definition of occlusal rela-
Systematic
Virtual surgery planning
tionships among dental specialties. Although there was no consensus regarding condylar position in relation
Orthognathic surgery to the fossa, the most reported axis of rotation was positioned posterior-inferior. Weak scientific evidence
Temporomandibular joint and divergences in dental vocabulary shows the need for clinical studies with more accurate and transparent
Terminal hinge axis methodological design to standardize concepts. Despite we cannot affirm, we can suggest that the centric
relation (CR) is not the condylar position when clinically manipulated in the posterior superior direction.
This condylar position is the retruded contact position (RCt) while CR is the functional position of the con-
dyle. In this way, the orthognathic surgery has two occlusal relationships during planning and execution. The
ideal axis of rotation for orthognathic surgery planning must be fixed, permit individualization for each con-
dyle and be reproducible. The 2D planning is obsolete as cannot provide all the necessary tools for an accu-
rate planning.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction surgery is planned and executed with a mandibular position that

Dentofacial deformities have a high global prevalence, ranging
from 47.2% to 86% [1−3]. Among the various treatment options,
orthognathic surgery is indicated when there is dentofacial dishar-
mony involving the bone base, with no possibility of orthodontic cor-
rection. Orthognathic surgery provides better interdental relations,
improved masticatory function, and adequate harmony in facial
esthetics [4,5]. Surgical planning and facial analysis are essential for
satisfactory results, and traditionally use the mandibular positioning
in centric relation (CR) for their realization [6−9].
The mandibular approach is different from approaches involv-
ing other facial bones as it is the only moving bone in the surgi-
cally addressed area. Thus, presurgical data are collected, and the
* Corresponding author.
E-mail address: matheusdabarretto@usp.br (B. MDA).
permits trans-operative reproducibility [6,9,10]. This is obtained
through the clinical manipulation of the mandible, using the con-
dyle-fossa ratio as a reference [11,12] until the first dental con-
tact is observed [6].
Traditionally, this mandibular position is termed as CR
[6−9,13,14]. However, the definition of CR is controversial and has
changed many times over the years [15−17]. Since 1987 the Glossary
of Prosthodontic Terms (GPT) [18] defines CR as a "maxillomandibu-
lar relation, regardless of dental contact, in which the condyles artic-
ulate in the anterior-superior position against the posterior slopes of
the articular eminences; in this position, the mandible is restricted to
a purely rotational movement; (...) is a clinically useful and reproduc-
ible reference position”.
Its description is not compatible with the manipulated mandi-
ble position [19]. Some authors refer to this as the retruded con-
tact position (RCt) [20]. Therefore, whether the CR is the most

https://doi.org/10.1016/j.jormas.2021.06.004
2468-7855/© 2021 Elsevier Masson SAS. All rights reserved.

Please cite this article as: B. MDA, M.-E. F and D. MCZ, Methods of mandibular condyle position and rotation center used
?for orthognathic surgery planning: a systematic review, Journal of Stomatology oral and Maxillofacial Surgery (2021), https://doi.org/
10.1016/j.jormas.2021.06.004
JID: JORMAS
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B. MDA, M.-E. F and D. MCZ
anterior-superior position of the condyle in its fossa as defined by
the GPT, or the reproducible condylar position for orthognathic
surgery as used by maxillofacial surgeons (the most posterior-
superior position in its fossa), remains unclear.
Furthermore, the determination of the condylar center of rotation
is also controversial [21−24]. For orthognathic surgery planning the
visual center of the condyle is determined as the center of rotation
for most surgeons [25−28], while others use the most posterior-
superior point of the condylar surface [29]. The procedure to rotate
the condyle in surgical planning to reproduce the mandibular open-
ing path is still unclear.
Both approaches to surgical planning, the traditional planning
(two-dimensional [2D]) [6,9,25] and the virtual surgical simulation
(three-dimensional [3D]) [30−32] use the condyle-fossa relation as a
reference.
We aimed to systematically review the 2D and 3D evaluations of
the mandible condyle position and its center of rotation. Additionally,
we presented whether these data could be reproduced in orthog-
nathic surgery planning.
2. Material and methods
The present review was structured according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyzes guide-
lines [33]. This review was registered in PROSPERO (International
Prospective Register of Systematic Reviews) with the registration
number: CRD42020191221.
2.1. Focused question
According to the PICO framework:
What is the most appropriate methodology to determine the axis
of condylar rotation and condylar position in articular, occlusal and
orthognathic surgery planning evaluation: 2D or 3D evaluations?
2.2. Search strategy and study selection
Search strategies were created for the PubMed, SCOPUS, Embase,
and Cochrane databases. MesH terms and keywords were combined
using Boolean operators and used to search these databases. The pres-
ent review had no language restrictions, and the search was performed
until August 12, 2020. The search strategy combined the following
MesH Terms: “(center of condylar rotation) AND virtual planning;
(center of condylar rotation) AND orthognathic surgery; (center of con-
dylar rotation) AND orthognathic; (center of condylar rotation) AND
orthognathic virtual planning; (center of condylar rotation) AND posi-
tion; (center of condylar rotation) AND simulation; (center of mandib-
ular rotation) AND orthognathic surgery; (center of mandibular
rotation) AND virtual planning; (center of mandibular rotation) AND
orthognathic; (center of mandibular rotation) AND orthognathic virtual
planning; (center of mandibular rotation) AND position; (center of
mandibular rotation) AND simulation; (axis of mandibular rotation)
AND orthognathic; (axis of mandibular rotation) AND orthognathic vir-
tual planning; (axis of mandibular rotation) AND virtual planning; (axis
of mandibular rotation) AND orthognathic surgery; (axis of mandibular
rotation) AND position; and (axis of mandibular rotation) AND
simulation.”
Two reviewers (MDAB and MCZD) independently searched for
potential studies, reading titles, and abstracts. The two reviewers
were evaluated for inter-class correlation, and disagreements were
solved through discussions with a third reviewer (FME). The same
reviewers independently evaluated the full text of the studies that
appeared to meet the inclusion criteria, to determine their eligibility.
Studies that met the inclusion criteria underwent data extraction and
risk of bias assessment. Reasons for the rejection of studies were
recorded.
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2.3. Inclusion criteria
Only full texts that included 2D or 3D evaluation of mandibular
condylar position concerning its fossa and rotational axis for orthog-
nathic surgery planning were considered eligible for the present
review. We also included any evaluation in humans or human bio
models, which included qualitative or quantitative assessment of
mandibular condyle position concerning the fossa and the rotational
axis position of the mandible.
2.4. Exclusion criteria
Critical reviews, singular case reports, systematic or non-system-
atic reviews, and animal and in vitro studies were excluded.
2.5. Data extraction and risk of bias assessment
The same reviewers extracted data from the selected studies using
extraction forms. The following variables were assessed: (1) author
and year; (2) country of publication; (3) type of study; (4) sex; (5)
sample size; (6) study models; (7) unilateral or bilateral evaluation;
(8) method to locate the position of the mandibular head and axis of
rotation; (9) condylar position in the fossa; (10) axis of condylar rota-
tion; and (11) instantaneous or fixed center of rotation. The authors
of the selected publications were contacted for clarification of data or
to provide missing data when necessary.
The risk of bias was evaluated independently by the same
reviewers according to the Cochrane collaboration’s tool adapted for
assessing the risk of bias [34] consisting of different domains: 1.
Patient selection: could the selection of patients have introduced
bias? Regarding the presence or absence of temporomandibular joint
(TMJ) dysfunction and clear methods of eligibility criteria; 2. Test
conduction: Was there any kind of blinding of observers or outcome
assessors? Was the method clearly described? 3. Test interpretation:
Could the interpretation of the test have introduced bias? There is a
clear description of the positioning and rotational axis protocol; 4.
Flow and timing: Could the patient flow have introduced bias? Were
all patients included in the analysis? and 5. Others: Was ethics com-
mittee approval considered?
Bias and applicability concerns were judged as follows: (1) low
risk of bias if all criteria were fulfilled (adequate randomization and
allocation concealment, a positive answer to all questions about the
completeness of outcome data and blinding, and a lack of answers to
selective reporting and other sources of bias); (2) unclear risk of bias
if one or more criteria were partly fulfilled; or (3) high risk of bias if
one or more criteria were not fulfilled. A third author (FME) solved
disagreements between the assessors.
3. Results
A total of 1,110 studies were recovered. After analyzing the titles
and abstracts, 918 were excluded. The remaining 192 articles were
read in detail. Of these, 74 were duplicate, 11 authors were not reach-
able, 10 were event abstracts, and 87 did not evaluate the axis of rota-
tion or condylar position. Finally, 10 articles were included in the
review, six involving 2D analysis, and four involving 3D analysis. The
flowchart of the search (Fig. 1) shows the number of selected and
excluded articles. Interclass correlation between the two reviewers
was 87%.
3.1. General characteristics of studies
All studies were prospective. Data on the characteristics of the
included studies are presented in Tables 1 and 2 (2D and 3D, respec-
tively). The studies were conducted in China [20], Japan [35], Brazil
[36], Argentina [37], the USA [38,39], Switzerland [40], Denmark [41],
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Fig. 1. Study flowchart.
Germany [42], and South Korea [43]. University programs or research
foundations financed eight studies in total or in part. Two studies did
not provide any information on the type of financing [35,37].
Most articles studied the position of the mandibular head and the
axis of rotation regardless of orthognathic planning. However, it was
possible to divide the 10 articles into two main methodologies: 2D
[35−39,41] and 3D [20,40,42,43]. The characteristics of each are
shown in Tables 1 and 2.
A total of 149 participants were evaluated in 10 studies. The sex
distribution was 57 men and 34 women [35,36,38,40,42,43]. Four
studies did not reveal the sex of their participants [20,37,39,41].
3.2. Risk of bias
The majority of studies included in the present review had a high
overall risk of bias [20,35−39,41−43], while one presented an unclear
risk of bias [40]. None of the studies had a low overall risk of bias.
Most of the studies lacked information regarding patient selection
[20,41,43], blinding of the participants, and approval by the respec-
tive ethics committees [20,35−41] (Fig 2).
3.3. Experimental models
3.3.1. Plaster models
Only four studies used plaster models [20,35,36,41]; however, one
[36] mentioned using type IV dental stone.
3.3.2. Occlusal relation
The occlusal relation in some studies was used to guide the condy-
lar position. Nine studies provided information and used many occlu-
sal relationships definitions. We grouped them according to the
Glossary definitions synonymous [18]: RCt [20,35,41]; CR, centric
occlusion (CO) and terminal hinge position (THP) [35,36,38]; maxi-
mal intercuspation position (MIP) and habitual occlusion (HO)
[36,37,39,40,42], while one did not provide any information [43].
3.3.3. Making of occlusal splint
To ensure that the planned occlusal relation was maintained
throughout the methodology, five studies used occlusal splints. Of
these, two were fabricated using wax [20,35], two others with
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anterior jigs [36,38], and one with acrylic resin plates [39]. The other
five did not use any occlusal splints [37,40−43].
3.3.4. Articular alteration
Seven studies reported no joint changes in the participants with-
out describing an evaluation method [20,35−39,42]. Three studies
performed clinical and/or imaging tests to assess joint conditions,
including only participants without joint changes [40,41,43].
3.3.5. Skeletal deformity
Seven studies did not mention the presence of skeletal deformi-
ties in patients [35−39,41,42]. Only two studies evaluated and classi-
fied participants as Angle
s skeletal Class I [40,43]. One study reported
that the participant had skeletal deformity without classifying the
deformity [20].
3.3.6. Occlusion
Of the 10 studies, five involved Angle
s Class I patients without
missing teeth [36,38,39,42,43]. Only one study included patients
with Angle
s Class I, II, and III, also without dental absences [40]. Four
studies did not assess the occlusal relations of their participants
[20,35,37,41].
4. Discussion
The method of planning orthognathic surgery has undergone sig-
nificant advances in recent decades, and virtual simulation has
allowed greater accordance between planned and executed
approaches. Evaluations previously done in 2D can now be per-
formed in 3D. Despite these advances, the methodology for precisely
rotating the mandible during virtual 3D simulation is still controver-
sial, as is the condylar position, which serves as a reference for the
execution of planning and reproduction in surgery.
To our knowledge, this is the first systematic review that sought
to comparatively assess the axis of rotation and the condyle of man-
dible position in 2D and 3D planning of orthognathic surgery. There
was no consensus on the condylar position concerning the fossa, and
most studies indicate that the axis of rotation is posterior-inferior
[36,37,39−41,43]. Although numerous methodological and concep-
tual limitations are present in all studies, their weak clinical scientific
evidence did not allow us to conclude about the accuracy of their
findings. The studies included in the review were heterogeneous;
therefore, it was not possible to perform a meta-analysis and assess
whether one method was superior.
Regarding quality assessment, instruments have been developed
to detect methodological weaknesses or limitations that might alter
the study results. Since the studies included in the present review
were rated as having a high or unclear risk of bias (Fig. 2), this analy-
sis should be interpreted with caution. Heterogeneity normally arises
from methodological differences between studies and can affect the
generalizability of the conclusions. However, all the studies pre-
sented a good flow and timing interval protocol.
Ethical concerns, refinement of techniques to characterize the con-
dyles included, and standardization of clinical trial protocols are some
of the issues that should be addressed in future studies. Despite the dif-
ficulties in performing clinical trials with standardized methodologies
and analyses, research should be more consistent in describing the
occlusal relationships used as the different interpretations of their con-
cepts could adversely influence the search for evidence.
The condyle-fossa position depends on some factors, such as the
occlusal relationship. A different condyle-fossa position is obtained
for each occlusal relationship. In this way, it is impossible to change
the occlusal interface of the bimaxillary relation without affecting the
position of the joints. Despite that, the selected studies demonstrated
different condylar positions derived from the same occlusal relation-
ship (Tables 1 and 2).
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Table 1
Bidimensional studies analysis. Study identification, methodology, sample size, evaluation, locating the condyle and axis of rotation, condyle-fossa position, axis of rota-
tion, ICR and FCR.
Study Material and Methods Evaluation Locating the condyle and axis of
(sample)
Torii et al., 1989 Wax occlusal split records in Unilateral
(35) 5 degrees of mandibular
opening and 3 occlusal
relationships (RCt, HO and
THP) of plaster models in
articulator. (n = 5)
Learreta et al., CBCT and profile x-ray based Unilateral
2013 (37) on unilateral sagittal slices
of the TMJ of the study
participants in MIP. 2
groups: individuals with
joint changes (n = 26) and
without changes (n = 34).
Lindauer et al., Profile X-ray at MIP in 6 Unilateral
1995 (39) degrees of opening with
occlusal splints on the 1st
molars. Each dental posi-
tion was scanned 5 times
(n = 8)
Nattestad et al., 2 profile x-ray in RCt, with 2 Unilateral
1992 (41) degrees of opening.
Sketchs were made on the
profile x-rays and rotated
5, 10, 15, 20 or 25 °.
(n = 10)
Ismail et al., 4 profile x-ray, 2 bilateral Bilateral
1980 (38) shots in CR and 2 others
bilateral in CO, all with
occlusal splints. (n = 40)
Venturelli et al., MRI images and condyle Bilateral
2009 (36) profile x-ray. Each exam
was performed at MIP and
with occlusal splints in CR.
Plaster models were also
evaluated, positioned in
the articulator; graph
paper was positioned in
the condylar device of the
articulator to record the
horizontal axis of rotation
in CR position. (n = 6)
(ICR) Instantaneous Center of Rotation; (FCR) Fixed Center of Rotation; (RCt) Retruded Contact; (HO) Habitual Occlusion; (THP) Terminal Hinge Position; (CBCT) Cone-
Beam Computed Tomography; (TMJ) Temporomandibular Joint; (MIP) Maximal Intercuspal Position; (CR) Centric Relation; (CO) Centric Occlusion; (MRI) Magnetic Reso-
nance Image; (NA) not evaluated.
Although there was no consensus on the condylar position con-
cerning the fossa in this review, only two studies directly evaluated
this variable [37,38]. Of these, one concluded that the mandibular
head is located posterior-inferior when in CR and centrally when in
centric occlusion [38]. The other [37] concluded that the condyle is
central to the articular fossa using maximal intercuspal position
(MIP). These divergences endorse the controversy on the subject,
indicate flaws in the conceptualization of the occlusal relationship
and will continue to confuse the outcomes until we master our dental
vocabulary.
Prosthodontists produced a Glossary [18] as a dictionary standard
for uniform terminology to dental communication. We assumed that
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Condyle-Fossa position Axis of rotation ICR FCR
rotation
Amplitude records analyzed Anterior-inferior. Anterior-inferior. No Yes
graphically and statistically on
the computer.
A sagittal section of the CBCT was Central. Posterior-inferior No Yes
selected for analysis, along with (10.72§6.23°).
the profile x-ray. 3 fixed points
in the glenoid fossa were deter-
mined as references, in cephalo-
metric analysis. Equations were
used to analyze the condylar
position and change the condy-
lar axis orientation.
Position of the incisors and molars NA Posterior-inferior. Yes No
used as references to locate the
condylar center. The position of
the condyle in the MIP was
defined as the center of the Car-
tesian coordinate system, with
the x axis parallel to the Frank-
furt plane, for analysis with Dol-
phin Sonic Digitizing System.
Two tangents parallel to the ante- NA Posterior-inferior. No Yes
rior and posterior contour of the
condyle head were drawn, it
crossing determined the middle
of the superior condylar surface.
Autocad Ò and Summagraphics
Supergrid Ò software were used.
Center of rotation, size of move-
ment and overlapping error
were determined for each indi-
vidual by equations.
Parallel tangents were drawn to Posterior-inferior when NA NA NA
measure the superior, anterior, in CR and central
and posterior articular spaces when in CO.
between the condyle and the
fossa. Keeping the distances
between the lines as close to
0.1 mm.
The images were transferred to a Posterior-superior when Posterior-inferior. No Yes
computer and analyzed using in MIP. In profile x-
AutoCAD 2000 software (Auto- ray, anterior-superior
desk Inc., USA). 3 points in the when in CR and is
glenoid fossa were determined posterior and more
to assess the condylar position. superior when evalu-
ated in MRI.
the absence of conceptual unification by dental specialties is one of
the reasons for this controversy, therefore we used the GPT [18] as a
reference to analyze the definitions of occlusal relationships in this
study. With the aim to stimulate interdisciplinarity and establish a
unified dental vocabulary, understandable regardless the geographic
location and specialty of dentistry.
An extensive literature review that evaluated more than 300
articles and book sections [15−17] showed the conceptual shift of CR
definition. Originally defined as the most posterior-superior position
of the condyles in its fossa, it shifted in 1987 to the most anterior-
superior position of the condyles in its fossa, regardless of occlusal
relationship [15−17]. The recent definition is the current used by the
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Table 2
Tridimensional studies analysis. Study identification, Material and Methods, sample size, evaluation, locating the condyle and axis of rotation, condyle-fossa position, axis of
rotation, ICR and FCR.
Study Methodology(sample) Evaluation Locating the condyle and axis of
rotation
Gallo et al., 1997 Opening and closing movements Bilateral
(40) until MIP were recorded in an
optoelectronic system. A tar-
get on each side was posi-
tioned on skin as close as
possible to the TMJ, with the
long axis parallel to the
Camper Plane. (n = 30)
Sadat-Khonsari Each participant had 1 cycle of Bilateral
et al., 2003 (42) their complete usual move-
ment of opening and closing
the mouth (HO) registered
through an extra-oral elec-
tronic articulator. (n = 8)
Ahn et al., 2015 (43) Through 3D computer simula- Bilateral
tions, the opening and closing
movements of the mandible
were created and simulated.
Creating a dynamic simula-
tion, which included the
bones, muscles, and associated
ligaments, using ArtiSynth
(biomechanical simulation
tool). The movement of the
mandible was limited based
on the contact eminence-con-
dyle, and the associated skele-
tal ligaments and muscles.
(n = +1*)
Dai et al. 2013 (20) CT images were acquired with Bilateral
individuals using wax occlusal
splints in RCt with 5mm open-
ing, for the construction of a
composite skull. (n = 5)
(ICR) Instantaneous Center of Rotation; (FCR) Fixed Center of Rotation; (MIP) Maximal Intercuspal Position; (TMJ) Temporomandibular Joint; (HO) Habitual Occlusion; (3D)
three-dimensional; (*) study utilized more than 1 subject, without specifying; (CT) Computed Tomography; (RCt) Retruded Contact; (NA) not evaluated.
Glossary [18]. The review also highlights that mandibular manipula-
tion is one of the most consistent and reproducible methods for
recording CR and maintain the controversy whether it is a functional
position or not.
However, how can the CR be the most anterior-superior position
of the condyles in its fossa and be obtained through mandibular
manipulation in the posterior-superior direction? We believe that
this method guides the condyles in the same path, opposing from the
CR definition. This discrepancy of clinical application and the CR defi-
nition was already demonstrated by Truitt [19]. His study evaluated
the consensus among orthodontists and maxillofacial surgeons as to
the definition of CR and showed 78% of consensus amongst the sur-
geons. They defined the CR as the most posterior-superior position of
the condyles in their fossa, while the orthodontists presented differ-
ent definitions. Despite the consensus, this is not the current CR defi-
nition [18].
We believe that these divergences are due to the conceptual shift
of CR definition occurred in 1987, and to the lack of unified conceptu-
alization that theoretically explains what is clinically observed.
Although only one of the included studies was conducted earlier than
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Journal of Stomatology oral and Maxillofacial Surgery 00 (2021) 1−8
Condyle-Fossa Axis of rotation ICR FCR
position
Movement data was filtered in slow NA Posterior- inferior Yes No
motion. An intracondylar point (24.3 § 4.2°).
was determined by palpation of
the lateral condylar pole, this
point was marked in skin. After
virtual identification, this coordi-
nate was changed by 15 mm in
the medial direction, obtaining a
point located inside the condyle.
Then was calculated the position
of finite axis of rotation in rela-
tion to the intracondylar point.
Was used the CADIAXÒ electronic NA The average global fluctua- No Yes
axiography system, to register the tion of the axis was 3.3 °.
mandibular rotation. Each The axis is located near
recorded data set included sagit- the condyle, when at rest.
tal, vertical and transversal coor- During mouth opening,
dinates of the right and left sides, they move posteriorly and
as well as the angle (g ) (repre- inferiorly. Then, anterior,
sents the mandibular rotation in and inferior, and finally
relation to the orbital plane of the anterior and superior.
articular axis). With the maximum
mouth opening, they are
again close to the condyle.
The ICR was recorded at each step NA Posterior-inferior. Yes No
during the simulation of opening
and closing, generating a graph.
The point at which the jaw
appears to rotate during opening
and closing has been determined
and used to locate a single axis of
rotation in the simulation.
To define the geometric center of Anterior-superior. Central. No Yes
each condyle, 3 lines were drawn
from 3 points marked in each
contour (external contour, inter-
nal and intermediate contour).
the shift [38], the others did not consider the current definition
[36,38]. While orthodontists and prosthodontics use the current GPT
definition [18], most maxillofacial surgeons still use the first version
because it seems to reproduce the mandibular manipulation to
orthognathic surgery planning.
Despite that, a few surgeons perceived that the current CR defi-
nition did not represent what is clinically observed. Thus, recently
used the concept of retruded contact position (RCt), instead of CR
[20,35,41], also presents on GPT [18]. It is defined as “contact of a
tooth or teeth along the retruded path of closure” and seems to rep-
licate the mandibular manipulated position, necessary to plan and
perform orthognathic surgery. Although we cannot affirm yet that
this is the true definition for the manipulated position, we can sug-
gest this paradigm shift based on comparative literature analyses.
Clinical trials and image analyses studies are necessary to proof this
evidence.
After these analysis and reflections on the occlusal relationships, we
suggest another paradigm shift related to orthognathic surgery. Differ-
ing from the CR used as the only standard reference for most surgeons
during the orthognathic planning and execution [6−9,13,14], we
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Fig. 2. Risk of bias graph.
observed two occlusal relationships in the whole orthognathic surgery
process: as stated, clinical manipulation obtains RCt, which is repro-
duced during surgical intermediate occlusion, using posterior-superior
mandibular guidance. In both manipulations, the condyle-fossa rela-
tionship is used as a reference. The second relationship is obtained dur-
ing the final surgical occlusion in MIP and the condyle-fossa
relationship approaches the GPT definition of CR [18]. In this surgical
step, the aim is to reach maximum dental intercuspation and other
bone reference measures. Although this methodology is clinically per-
formed by all surgeons, it has not yet been directly described. The diffi-
culty in conceptualizing what is already accomplished may be a reason
behind many controversies in this field.
To suggest that, it is important to remember that: 1. the CR is a
condyle-fossa position regardless of dental occlusion [18] and 2. the
CR is the physiologic condylar position of a healthy condyle, due to
the retro discal ligament constrain the backward movement of the
condyle, thus, a functional position. This differs from Keshvad et al.
[17], who affirms that is still controversial if the CR is a functional
position. As a physiologic position, the CR is obtained with the patient
in a relaxed position, differing from the RCt that is obtained through
mandibular manipulation.
Most of included studies presented methodological and sample
characterization flaws. Regarding occlusal splints, half of the included
studies used it to acquire the images that served as the basis for their
analyses [35,36,38−40]. Therefore, those who did not use [37,40−43]
did not provide a reliable result on the condylar position for the eval-
uated occlusal relationship. Concerning dental casts, four studies
included reported the use [20,35,36,41] and only one [36] reported
the use of type IV dental stone. As the type IV has high strength and
low setting expansion [44], it is the standard for precise evaluations
[45].
Involving the presence of skeletal deformities in the participants,
most of the included studies did not mention whether they assessed
the presence and, when present, did not classify them [35,37
−39,41,42]. Those who rated and classified [40,43] did not evaluate
6
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Journal of Stomatology oral and Maxillofacial Surgery 00 (2021) 1−8
the condylar position. Previous studies have sought to assess the rela-
tionship among different skeletal deformities and condylar positions;
however, it is still controversial [46−49].
Despite all the included studies affirmed that selected only
patients without condylar alterations, only three performed imaging
evaluations [40,41,43]. As previous studies have demonstrated that
these alterations can modify the mandibular opening path [50], those
who included alterations or did not perform imaging evaluations, did
not provide a reliable result of the condylar position [20,35−39,42].
Studies with standardized methodologies and rigorous characteriza-
tion and selection of the sample, have reduced the risk of inconsisten-
cies in the quality of surgical planning.
This review indicates that the axis of rotation is posterior-inferior
[36,37,39−41,43]. Despite other studies that sought to find the “real”
condylar rotation center have showed that it is located outside the
condyle, in different positions, distances, and angulations
[6,29,35,41,50−52]. Two main reasons for this great divergence were
observed in this review: 1. Measurement inaccuracies of the different
methods and devices for capturing movement, and 2. Deformation of
soft tissue where the sensor was positioned.
Due to the significant heterogeneity of the studies, it was not pos-
sible to indicate one method’s superiority in determining the axis of
rotation. Despite two studies have presented interesting methodolo-
gies to determine it [42,43], both used high-cost 3D technologies
associated with computational software to perform their evaluations.
On reason of this and the difficulty to reproduce them clinically, they
showed minimal clinical applicability.
The 2D and 3D ways to determine the condylar center of rotation
can be grouped in two approaches. 1. Fixed axis of rotation (FAR)
[20,35−37,41,42], a simplified and clinically reproducible method;
and 2. Instantaneous axis rotation (IAR) [39,40,43], which seeks to
precisely describe the entire path taken by the condyle during open-
ing and closing movements. We believe that most studies used a FAR
to seek a simplified and reproducible methodology and the IAR has
its limitations for the clinical dental procedure.
Besides that, each condylar center of rotation is an individualized
measurement as the condyles and their fossa in the same individual
are not anatomically equal [50]. This suggests two different centers
of rotation per individual, and their association leads to the final
movement performed by the mandible. In this way, the 3D images
are the gold standard to planning orthognathic surgery as it enables
individual condyle analyses without overlapping (Computed Tomog-
raphy or Cone-Beam Computed Tomography), which is common in
2D images [53].
For planning orthognathic surgery, sometimes is necessary a
short mandibular rotation. This happens to remove some overlap
of the jaws, that may arise during the planning or to guide the
jaws in occlusion to the manufacture of surgical splint. In this
way, minimal errors in determining the axis of rotation can lead
to major errors in jaws positioning [41]. Despite the total man-
dibular opening movement is composed of rotation and transla-
tion, a mandibular rotation up to 20 mm is purely rotational, as
stated classically by Posselt [54]. This short opening is sufficient
to perform the virtual surgical simulation, and to determine a
fixed axis of rotation. With the limitation that it applies only to
movements up to 20 mm, above this a translation movement is
associated with the rotational.
Therefore, we believe that a simple methodology that allows the
identification of a point, customized to the individual condyle, and
provides reproducible and reliable surgical planning is the goal in
orthognathic surgery planning. Thereby, a study [20] used virtual sur-
gical planning with the mandible manipulated in RCt, and obtained a
geometric center of the 3D condyle. Although significant results were
presented, the small sample size and poor methodological rigor may
raise doubts about the achievements. Some steps could have been
taken to reduce bias, such as blinding observers during data
JID: JORMAS
ARTICLE IN PRESS
B. MDA, M.-E. F and D. MCZ
collection, verifying methodological reproducibility, and including
more than one calibrated observer.
In this aspect, the 2D planning methodology is insufficient and
imprecise. Cephalometric tracing adopts a single point as the center
of rotation for both condyles, and the facial arch also performs this
generalization when transferred to the articulator. Owing to the
inability to provide the individualized planning necessary to deter-
mine the axis of condylar rotation, we consider the traditional plan-
ning as well as the 3D ones that employ it as obsolete.
Despite the preferred method for surgical planning is that the pro-
fessional has more skills. The limitations of 2D surgical planning and
the advantages of 3D virtual surgical simulation should be under-
stood. Technological improvements have brought innovative meth-
odologies, and professionals should be prepared to incorporate this
new knowledge. The 3D images are superior to 2D images [53] and
cast models must be constructed using type IV dental plaster [44].
Another option is the intraoral scan, which allows a reliable and accu-
rate final digital occlusion [55]. Occlusal splints are essential for
acquiring images that can reproduce the clinically manipulated
occlusal relationship [30,56] and this occlusal position must be
defined.
Despite the advances offered by the integration of 3D technologies
in the planning of orthognathic surgery, it is futile if traditional con-
cepts are exactly replicated in this new approach. We must adapt
existing knowledge to this new form of technological management. If
we do not employ 3D technology to enable the condyles individuali-
zation, we will continue to plan in a flawed and incomplete way,
using technology with a high-cost and steep learning-curve.
Within the limitations of this systematic review, it can be consid-
ered that although most studies have pointed out that the axis of
rotation is located posterior-inferior to the condyle, the heterogene-
ity of the studies did not allow us to present a simple and reproduc-
ible methodology for determining it. The determination of an axis of
rotation is still necessary and ideally it must be fixed, permit individ-
ualization for each condyle and be reproducible.
Despite we cannot conclude, divergences in the literature sug-
gests that the RCt is the obtained position through the clinical man-
dibular manipulation, while the CR is the functional position of the
condyles. Also, the orthognathic surgery is done with two occlusal
relationships: RCt to plan and obtain the intermediate occlusion, by
posterior-superior mandibular guidance; and MIP to final surgical
occlusion and the condyle-fossa relationship in CR.
It’s imperative the use of Glossary of Prosthodontic Terms as a
standard reference for unified communication and research amongst
the dental specialties. The 2D planning is obsolete as cannot provide
all the necessary tools for an accurate planning, also the 3Ds that can-
not apply the tools to promote accuracy and individualization.
Author’s contribution
Matheus Dantas de Arau
jo Barretto: Data collection, analysis,
manuscript writing and editing.
Maria Cristina Zindel Deboni: Data collection, analysis, manuscript
writing and editing.
Fernando Melhem Elias: Analysis and editing.
Ethical approval
Not applicable.
Declaration of Competing Interest
The authors declare that they have no conflict of interests.
7
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Journal of Stomatology oral and Maxillofacial Surgery 00 (2021) 1−8
Funding
Scholarship - Coordination of Superior Level Staff Improvement
(CAPES.
Acknowledgments
To Professor Chiarella Sforza and to Professor Jiewen Dai to have
sent a paper copy and the data from their study.
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