Comparative Evaluation Of Clinical And

Radiographic Horizontal Condylar Guidance Angle

Values By Using Two Different Interocclusal
Recording Materials In Dentulous Patients
Dr. Kavya Sai Sree Uttaradi, Senior Lecturer, Department Of Prosthodontics, Sibar Institute Of Dental Sciences, Takkellapadu,
Guntur. Email Id: kavyasree.uttaradi@gmail.com / uttaradikavya696@gmail.com.

Dr. Krishna Kishore Kadiyala, Professor and Head Of The Department, Sibar Institute Of Dental Sciences, Takkellapadu, Guntur.
Email Id: drkkthetusker@gmail.com.

Dr. Haragopal Surapaneni, Reader, Department Of Prosthodontics, Sibar Institute Of Dental Sciences, Takkellapadu, Guntur.
Email Id: haragopal.surapaneni@gmail.com.

Dr. Lakshmi Mounika Kalluri, Senior Lecturer, Department Of Prosthodontics, SibarInstitute of Dental Sciences, Takkellapadu,
Guntur. Email id: kallurilakshmimounika@gmail.com.

Dr. Deepika Madala, 3rd Year Post Graduate, Sibar Institute of Dental Sciences, Takkellapadu, Guntur. Email id:
madaladeepika1995@gmail.com.

Dr. Nayeema Sultana, 2rd Year Post Graduate, Sibar Institute of Dental Sciences, Takkellapadu, Guntur. Email id:
nayeemabds@gmail.com.
DOI: 10.47750/pnr.2022.13.S06.253

Abstract
Introduction: The success of prosthodontic procedures can be accurately determined by the exact replication of the patient’s
condylar path using a semi-adjustable articulator. It allows the clinician to determine the morphology of the occlusal surfaces in
relation to the condylar pathway during mandibular movements. If condylar guidance is not exactly registered, it might result in
occlusal interferences during movements of the mandible and lengthen chairside adjustment time, which is inconvenient for the
patient and dentist.
Materials and methods: A total of 20 dentulous patients from 20 to 30 years of age group attending the department of
prosthodontics at Sibar institute of dental sciences were selected for the study. Alu wax and jet bite were used to obtain the
protrusive interocclusal record (PIR). Protrusive records were then used to program the semi-adjustable articulator to obtain
HCGA values on both sides. Using the same protrusive records CBCT radiograph was taken. Radiographic images were traced
on tracing paper and HCGA values were measured using Frankfort’s horizontal reference line (the line connecting porion and
orbitale) and the mean curvature line (most-superior and most-inferior points of the curvatures) on both sides using a protractor.
The data were analyzed by paired sample t-tests and Pearson’s correlation tests.
Results: There was no significant difference between the right and left sides in the clinical and radiographic methods using Alu
wax PIR. In the clinical method utilizing jet bite PIR, the right side had significantly higher HCGA values than on the left side.
On CBCT, no such differences were found.
Conclusion: CBCT horizontal condylar guidance angle values were higher than those obtained using the clinical method by
using both records. Values obtained from both the methods, i.e., protrusive interocclusal record and cone-beam computed
tomography, were compared and correlated.

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1949

Keywords: Alu wax, Jet bite, Protrusive interocclusal record (PIR), Horizontal condylar guidance angle (HCGA), Frankfort's
horizontal plane (FHP), and Cone Beam Computed Tomography (CBCT).

Introduction:
Prosthetic dentistry intends to regain missing tooth morphology and re-establish an ideal occlusion in accordance
with the stomatognathic system of the patient. Among five factors that influence the laws of articulation as given by
Hanau, the most important factor in establishing balanced articulation and the most predominant consideration in
(1)
any patient's oral rehabilitation is condylar guidance. AccordingtoGPT9,Condylar guidance is defined as the
mandibular guidance generated by the condyle and articular disk traversing the contour of the articular eminence.
Research into the mechanism of condyle and efforts to register movements of the mandible began in the
18th century.(2) The "protrusive wax check bites" described by Christensen in 1905 and the graphic approach
(1)
introduced by Gysi in 1908 were the first methods used to record the HCG. Since then, many authors have
conducted research to determine the HCG using a variety of approaches and compared the variability between
different registration techniques, articulator systems, and recording materials.
There are three basic methods for obtaining HCG: (1) Intraoral methods, (2) Extraoral methods, and (3)
Radiographic methods. Intraoral methods such as protrusive wax interocclusal records, leaf gauge, Lucia jig, and
(3)
intraoral tracers can be utilized to determine the mandible's centric and eccentric relationships. Intraoral record
regardless of the type of material employed, represents only one position along the condylar path and horizontal
(4)
condylar guidance angle (HCGA) varies with the degree of protrusion. Even if the registration methods are
followed precisely, inaccuracies may occur due to friction interference of smooth movements between the
articulator's condylar components.(3,5) Extraoral methods include radiographs and pantographs. Boos attempted to
record the condylar path using a temporomandibular radiograph in 1951 to identify condylar guidance. During the
1970s to overcome the disadvantages of clinical approaches, authors such as Corbett et al. (1971), Ingervall (1974),
Christensen and Slabbert (1978) proposed radiographic methods of recording the HCG.
Radiographic techniques include lateral cephalograms, panoramic radiographs, and computed tomograms.
(5) (2,6,7)
They are more accurate as it includes stable bony landmarks and can be easily standardized. Although
panoramic radiographs and lateral cephalograms provide a two-dimensional (2D) image of the temporomandibular
joint (TMJ),(5)CBCT, as a more advanced cutting-edge technology, provides three-dimensional (3D) multiplanar
sections without superimposition, allowing the glenoid fossa and articular eminence to be clearly seen from the
surrounding structures.(5,8)Tomography scans, on the other hand, have been safer, requiring less radiation exposure
and becoming more effective since the introduction of CBCT, resulting in its outspread usage in dentistry. (9)
However, the limitations of CBCT include the high cost of the equipment. (10,11)
Most of the studies used panoramic imaging and lateral cephalograms for recording HCGA.(2)There are
very few studies comparing clinical and radiographic procedures employing CBCT. So, the goal of this study was to
compare HCGA values obtained from protrusive interocclusal records of two different materials (Alu wax and Jet
bite – polyvinyl siloxane) with the CBCT (panoramic section) radiography technique.

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1950

Materials and Methods:
The study was conducted in the Department of Prosthodontics, Sibar institute of dental sciences, Guntur, Andhra
Pradesh, India. Written consent was obtained from all the patients. Twenty patients aged between 20 and 30 years
with a full complement of dentition fulfilling the following criteria were selected.

Inclusion Criteria: Inclusion criteria are Angle’s Class I molar and incisal relations, individuals with impacted third
molars, absence of crowded or maligned teeth, good oral hygiene, and periodontal status.
Exclusion Criteria: Exclusion criteria are facial or skeletal malformations, Poor neuromuscular coordination, and
Individuals with severe Temporomandibular joint disorders (myofascial pain dysfunction syndrome, osteoarthritis,
internal derangements, rheumatoid arthritis, ankylosis, tumors, trauma, and developmental disorders), deteriorating
general health.

A) Making of impression & obtaining casts:

Diagnostic impressions were made using a stock tray (perforated stainless steel) using irreversible hydrocolloid
impression material. The impressions were rinsed, dried, inspected, and disinfected using 2% glutaraldehyde (Cidex)
for 10 minutes and the cast was poured with type III dental stone. Six wedge-shaped notches were made at the top of
the maxillary cast forthe split cast where two notches toward the outer edge of the posterior border, two in the first
molar region, and two in the lateral incisor region.
B) Face bow transfer
Facebow transfer was done using a hanau spring bow and this assembly was transferred to the articulator using
indirect mounting transfer and the casts were mounted (Figure 1 and Figure 2).
C) Interocclusal bite registration method:
To obtain records initially, the patient was trained to move the mandible forward till the teeth are in an edge-to-edge
relationship. Two bite registration materials were used, i.e., alu wax and jet bite (polyvinyl siloxane). To obtain a
wax record a two-sheet thick alu wax rim is adapted to the maxillary arch and the patient was asked to move the
teeth into edge-to-edge relation (Figure 3 and Figure 5). This record was transferred to the articulator (HANAU
Wide-Vue Articulator). Protrusive relation was assessed and reconfirmed before setting the horizontal condylar
inclinations, and locknuts were tightened. In all the cases, the articulator was programmed by a single operator only.
D) Programming of articulator:
In this study, Hanau articulator was modified to obtain accuracy of condylar guidance. The articulator has a
numerical scale condylar track with 5° increments. A protractor with angulations from 0° to 60° was mounted to the
condylar shaft for more precise values. The protractor's center was set to align with the condylar shaft's center.
While measuring the angle, the protractor's 0° was aligned with the 0°pointer. A 23-gauge orthodontic wire was
used to make an L-shaped extender and was attached to the zero-reference line. While interpretation, if the
protractor's pointer was at 0.5mm or more, the higher value is considered as the reading, and if the pointer was at
less than 0.5mm, the lower value is considered. To determine the horizontal condylar guidance articulator condylar
locks were loosened, and the protrusive record was positioned on the mandibular cast. The maxillary cast was placed

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1951

on the imprints of the protrusive record. The upper member of the articulator was adjusted sothat the maxillary cast
would seat into the indentations of the split cast, and the two parts were held together firmly (Figure 4 and Figure 6).
Readings of the condylar guidance angle values on the right and left sides of the articulator were recorded. Same
procedure was repeated three times until two similar values are obtained (Figure 7). The condylar screws were
tightened, and the right and left condylar readings were recorded and calculated.
E) Radiographic method:
CBCT was obtained with the patient’s mandible in a protrusive position along with bite registration material (Figure
8). Articular eminence and mandibular fossa were identified on both the right and left sides (Figure 9). Tracings
were done on the CBCT image, i.e., the Tangent of the Posterior slope of the articular eminence was drawn, a line
joining the superior most point of the external auditory meatus (Porion) and the Inferior most point of orbital margin
(Orbitale) were marked. This represents the radiographic horizontal condylar guidance angle (Figure 10). The angles
between these two lines were evaluated by using a protractor.

FIGURE 1 FIGURE 2 FIGURE 3 FIGURE 4

115 5 5

FIGURE 5 FIGURE 6 FIGURE7

FIGURE8 FIGURE9 FIGURE10

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1952

Statistical Analysis: Statistical analysis was done using SPSS version 20 software (IBM Corp., Armonk, NY,
USA). Descriptive statistics, paired sample t-tests, and Pearson’s correlation coefficient tests were done to analyze
the study data. Bar charts and matrix scatter plots were used for data presentation.

Results Summary:
Table 1 represents the comparison of horizontal condylar guidance angle values between the right and left sides in
both CBCT and clinical method using Alu wax protrusive inter-occlusal record. There were no significant
differences between the right and left sides in both the clinical and radiographic methods (Figure 1). Significantly
higher horizontal condylar guidance angle values were observed on the right side in the clinical method using jet
bite protrusive inter-occlusal record when compared to the left side (Table 2). No such differences were observed in
the CBCT evaluation (Figure 2). Comparison of horizontal condylar guidance angle values between CBCT and
clinical method using Alu wax protrusive inter-occlusal record was done on right and left sides. Significant
differences were noted with higher mean horizontal condylar guidance angle values documented using CBCT
compared to the clinical method. Similar observations were made with regard to jet bite protrusive inter-occlusal
record using CBCT, demonstrating significantly higher mean horizontal condylar guidance angle values on both the
right and left sides.

Table 1: Comparison of horizontal condylar guidance angle values between right and left sides in both CBCT
and clinical method using Alu wax PIR

Method Side Mean N Std. Std. t value P value

Deviation ErrorMea
n

RIGHT 0.068 0.948

31.90 10 2.767 .875

Clinical LEFT 31.80 10 4.917 1.555

-0.525 0.612

RIGHT 37.00 10 2.160 .683

LEFT 38.00 10 6.146 1.944
CBCT

Pairedsamplesttest;p≤0.05consideredstatisticallysignificant;PIR–ProtrusiveInter-occlusalRecord

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1953

 Figure 1: Comparison of horizontal condylar guidance angle values between right and left sides in both
CBCT and clinical method using Alu wax PIR

Table 2: Comparison of horizontal condylar guidance angle values between right and left sides in both CBCT
and clinical method using Jet bite PIR

Method Side Mean N Std. Std. t value P value

Deviation ErrorMea
n

2.753 0.022*
RIGHT 37.00 10 2.357 .745
Clinical
LEFT 35.40 10 1.647 .521

0.874 0.405
RIGHT 40.20 10 2.573 .814
CBCT
LEFT 39.60 10 1.265 .400

Paired samples t test; p≤0.05 considered statistically significant; * denotes statistical significance; PIR – Protrusive
Inter-occlusal Record

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1954

 Figure 2: Comparison of horizontal condylar guidance angle values between right and left sides in both
CBCT and clinical method using Jet bite PIR

Discussion:

The relationship between the occlusal surface morphology and the condylar path traced during mandibular
movements have been well documented. Gysi (1910), Gilis(1926), and Gysi & Kohler (1929) were the first
investigators to recognize the importance of determining the horizontal path of condyles while restoring occlusion
in patients.(1) HC Gangles range from5º-55º in studies conducted by various authors. (Zamacona, Otaduy,
Aranda,1992., dosSantos Jr, Nelson, Nowlin, 2003., Lundeen, Wirth, 1973., Woelfel, Winter, Igarashi, 1976.,
Hobo, Mochizuki, 1982). (12)

The oldest method of recording HCGA is by using an interocclusal record.(13,14,15) It is a widely practiced
and accepted clinical method to record horizontal condylar guidance angle values
(12)
(Posselt,1968.,Mohl,et.al.1988.,Posselt,1968.,Rosensteil,Land,&Fujimoto, J.2006). Alu wax and Poly vinyl
siloxane were chosen as materials of choice to obtain inter-occlusal protrusive records in this study. In comparison
to base plate wax, Millstein et al. discovered that adding 0.05 mm thick aluminum laminate between wax wafers
loaded with copper particles enhanced accuracy. In comparison to the wax recording materials, the Coprwax
aluminum laminated, metalized wax wafer has shown less distortion.(16)Breeding and Dixon investigated the
compression resistance of numerous elastomeric interocclusal record materials. He stated that interocclusal

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1955

recording material made of poly vinyl siloxane had the best compression resistance.(17) .

Another method of recording HCGA used in this study was utilizing radiographs.(4) Radiographic methods
have been demonstrated to record horizontal condylar guidance more precisely than other methods (dosSantos
Júnior, Nelson, & Nummikoski,1996., Christensen,& Slabbert, 1978., Gilboa, Cardash, Kaffe, & Gross, 2008).
Christensen and slabbert stated that "No radiographically determined sagittal condylar guidance angle corresponded
with that acquired using intra-oral records". The angle determined by radiographs had a higher mean value than the
clinical data.(6)

The clinical and CBCT radiographic image of the sagittal outline of the articular eminence and glenoid fossae
was identified in all 20 subjects. Using Alu wax PIR horizontal condylar guidance angle values between the right
and left sides in the clinical method were 31.90° and 31.80°. Using Alu wax PIR horizontal condylar guidance angle
values between the right and left sides by CBCT method were 37.00°and 38.00°. Using jet bite PIR horizontal
condylar guidance angle values between the right and left sides in the clinical method were 37.00° and
35.40°.Using jet bite PIR horizontal condylar guidance angle values between right and left sides by CBCT method
were 40.20°and 39.60°.Comparison of horizontal condylar guidance angle values between the clinical method and
CBCT using Alu wax PIR on the right side were 31.90° and 37.00°. Comparison of horizontal condylar guidance
angle values between the clinical method and CBCT using Alu wax PIR on the left side were 31.80° and 38.00°.
Comparison of horizontal condylar guidance angle values between clinical method and CBCT using jet bite PIR on
the right side were 37.00°and 40.20°.Comparison of horizontal condylar guidance angle values between clinical
method and CBCT using jet bite PIR on the left side were 35.40° and39.60°.

There was no significant difference between the right and left sides in both the clinical and radiographic
methods using Alu wax PIR. In the clinical method utilizing jet bite PIR, the right side had significantly higher
horizontal condylar guiding angle values than the left side. On CBCT, no such differences were found. Condylar
guidance values recorded using CBCT were higher than those obtained using the clinical method by using both the
records.

According to the literature, the right and left eminences rarely have the same slants and contours. Csado et al,
Shrestha et al, and Prasad et al found smaller mean differences between the right and left HCG angle in their studies.
These values are statistically not significant but clinically and radiographically, the value of HCG angles was higher
on the right side as compared to the left side.(13) Alshali et al. found no statistically significant differences in sagittal
condylar inclination values between the male and female groups or between the right and left sides. Sagittal
condylar inclination angle decreased with age on both the right and left sides, with statistically significant changes in
values for both methods. Godavarthi et al found that the condylar guidance angle for the right and left sides was
38.62ºand38.05ºrespectively, which was statistically insignificant.(8)

Gilboa et al. discovered a positive association between anatomic and radiographic angles for articular
eminence inclination, with correlation coefficients of 0.561 and 0.802 for the left and right sides,
respectively.(18)According to a study by Kaur S et al., the mean difference in the angles of inclination of the inferior
border of the zygomatic arch measured by radiographic and anatomic methods was 8 and 8.47 for the left and right

Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1956

sides, respectively.(19)

In this study CBCT values are on an average of 6° - 7° higher than the clinical method utilizing alu wax
interocclusal record. CBCT values onan average of 3° - 4° higher than the clinical method utilizing Jet bite
interocclusal record. Based on this study CBCT values have a
moderatecorrelationwiththeclinicalmethodutilizingjetbiteinterocclusalrecords.

Tannamala et al found a 2° - 4° difference in HCG angle between OPG and the protrusive occlusal record,(20)
while Shreshta et al found a9°- 10° difference in HCG angle between CBCT images and the protrusive occlusal
record,(6) and Das et al found no significant difference in HCG angle between CBCT images and the protrusive
occlusal record.(8) Shetty and colleagues also found higher condylar guidance values from the radiograph when
evaluating the reliability of programming the articulator using the radiographs and the interocclusal records.(21)
Radiographically determined condylar angles provided greater results than intraoral recording techniques, according
to Christensen et al. In a study by Vadodaria, condylar guidance acquired by CBCT was about10°higher than
clinical methods, as evidenced by Jerath(14) et al, Kwon (9)
et al, and Naqash(2) et al, who found that HCG angle
values acquired from CBCT measurements were 5°– 6° higher than those obtained from protrusive occlusal
records.

In general, the results of this investigation show that none of the clinical approaches were found to provide
condylar guidance angle values that were comparable to the CBCT. Dimensional changes in materials, in accuracies
discovered in the casts, or failure to achieve the desired accuracy of the fit of interocclusal record on the occlusal
surfaces are all possible reasons for the drawbacks of the clinical method. (22) According to Muller et al, the removal
and placement of the record eventually produce discrepancies. According to Donegan and Christensen the common
reason for the inconsistency of intra oral methods is that the horizontal condylar angle changes with the degree of
protrusion, regardless of the material selected.(4,6) According to Ratzmann et al, Intraoral method of recording
condylar guidance angle, have inferior levels of reproducibility and are prone to variation in the operator,
instrument, and occlusal records.(6)

CBCT scans for condylar measures may be beneficial, especially in the case of complex oral rehabilitations.
To corroborate the current findings, substantially higher sample sizes with Condylar Guidance angle values are
required to confirm the current findings. This would ease the procedure to establish a predictable occlusal scheme in
the prosthetic rehabilitation of patient.

Summary and Conclusion:

Although many clinicians depend on the average condylar guidance angle values ranging from 22 ° to 65 ° for the
fabrication of the prosthesis, occlusal harmony could not be established since the HCI of the patient did not match
with the patient’s own values. HCGA values obtained via radiographic techniques can be utilized directly to
program the semi-adjustable articulators, eliminating the need for technique-sensitive-dependent clinical approaches
which are dependent on the operator or patients' neuromuscular control.

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Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1957

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Journal of Pharmaceutical Negative Results ¦ Volume 13 ¦ Special Issue 6 ¦ 2022 1958