DENTAL TECHNIQUE

The patient-specific anatomical articulator

Shereen S. Azer, BDS, MSc, MSa and Evan Kemper, CDT, TEb

Simulating the human jaw ABSTRACT

movements to accurately Currently available dental articulators have limitations for reproducing human mandibular
fabricate complex prostho- movements. The present article describes an innovative device that is a true patient-specific
dontic restorations is chal- anatomical articulator that accurately simulates patient anatomy and eliminates all technique-
lenging. More than 2 centuries sensitive mounting procedures, thus substantially diminishing potential errors in mounting and
ago, Gariot invented the first articulator settings. By using three-dimensional (3D) printing technology, patient cone beam
mechanical articulator in 1805, computed tomography (CBCT) data are used to print 3D replicas of the condylar fossae, as well
as the actual condyles, at the correct intercondylar distance. The maxilla (maxillary teeth and
which became to be known as
edentulous ridge) is printed with the correct spatial relationship to the condylar complexes and
the plane hinge or plane line the Frankfort horizontal plane (FHP). Those printed structures are then premounted onto a
articulator, and, in 1840, Evans modified articulator frame to render it “anatomic.” This new custom anatomical articulator, which
presented a modified version accurately mimics patient anatomical movements rather than relying on average values,
to simulate mandibular excur- represents the first truly fully adjustable articulator that is more precise than can be generated
sive movements.1 In 1858, by a pantographic tracing. It saves money, time, and effort by eliminating earbow transfers and
William Bonwill invented his mounting errors in complex prosthodontic treatment. (J Prosthet Dent 2021;-:---)
articulator, which was essen-
tially driven by the laws of mechanics as he envisioned depressor muscles, as well as the anatomy of the
them being related to mandibular movements. The term temporomandibular joints (TMJs) and associated struc-
anatomical articulator was first mentioned by Bonwill in tures such as the articular discs, joint ligaments, and bony
1899 while attempting to defend his work and silence his articular eminences.3,4 Multiple classification systems for
critics, proving that his articulator reproduced the rela- these devices have been published, ranging from simple
tionship of the glenoid fossa contours and the guidance to fully adjustable types. These were based on criteria
of teeth.2 Interestingly, he acknowledged that the shapes such as descriptive purposes, designs, concepts, and
of the fossae are never the same angle on either side. He capability and on the types of intraoral records that the
questioned the existence of any art or mechanical rules device accepts to allow the setting of its controls.5-13
that would regulate the beginning and ending jaw Currently, 4 articulator classes are acknowledged by the
movements.2 The Bonwill articulator was certainly far American College of Prosthodontists (ACP): Class I ar-
from being anatomical. ticulators are simple holding instruments that may allow
Since that time, myriads of articulator devices have vertical movement; class II articulators allow horizontal
been produced and marketed to serve the dental pro- and vertical movements but do not orient the motion to
fession. These instruments have been constantly modi- the TMJs; class III articulators (semi-adjustable) allow for
fied over the years based on the increasing knowledge of cast orientation relative to the joints and are able to
the dynamics of human mandibular movements and the simulate condylar pathways by using mechanical aver-
stomatognathic system as influenced by the elevator and ages for the movements; class IV articulators (fully

Presented at the 67th Annual Meeting of the AAFP, February 23-24, 2018, Chicago, Illinois. This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
a
Associate Professor and Vice Chair, Division of Restorative and Prosthetic Dentistry, The Ohio State University College of Dentistry, Columbus, Ohio.
b
Application Engineer, Whip Mix Corporation, Louisville, Ky.

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adjustable) are additionally capable of accepting 3D dy-

namic registration within obvious limits and hence come
close to simulating mandibular movements as far as is
“mechanically” possible.14
For most oral rehabilitations, accurate mounting of pa-
tient casts onto a semi-adjustable articulator is considered a
standard practice that entails several procedures. An earbow
transfer with an arbitrary hinge axis location using a third
point of reference is necessary to correctly capture the
relationship of the maxillary teeth to the transverse hinge
axis (THA), as well as to the Frankfort horizontal plane
(FHP). This enables mounting of the maxillary cast onto the
upper member of the articulator in the same spatial rela-
tionship as the patient.15-18 The upper member of the
articulator represents the FHP when set parallel to the floor/ Figure 1. Cone beam computed tomography scan converted to
bench top (with incisal pin set at 0). The earbow transfer standard tessellation language file format.
device orients the maxillary cast in space relative to the THA
and the FHP. A centric relation (CR) record is then required
to mount the mandibular cast to the already mounted
maxillary cast. Furthermore, protrusive and lateral records in condylar determinants.33-37 One particular determi-
are required to program the articulator to replicate function, nant of condylar movement, the immediate mandibular
expressed in protrusive and lateral jaw movements. lateral translation (IMLT) of the condyles, has been the
This entire mounting process is technique sensitive, subject of considerable debate and confusion in the
must be accomplished as accurately as possible, and is prosthodontic literature.38-40 However, a recent system-
still challenging. Teteruck and Lundeen19 compared atic review of the literature reported a lack of evidence for
mounting maxillary casts by using the traditional facebow the clinical significance or implications of this
and the classic 13-mm tragus-canthus point (arbitrary movement.41
hinge axis) to the kinematic (true) hinge axis. It was In general, when articulators are used to fabricate
found that 33% of the arbitrary axis points fell within a 6- dental prostheses, average articulator values are usually
mm radius of the kinematic axis. However, with the use used by practitioners and dental laboratory technicians. It
of an earbow, this percentage increased to 56.4% and to is thus logical to expect that the resultant inevitable
75.5% accuracy with a simple anterior modification of the prosthetic errors need to be corrected or adjusted intra-
ear plug.19 Others have investigated the resultant orally, consuming precious chairside time.
mismatch between the arbitrary and kinematic axes on The purpose of this article was to introduce to the
the accuracy of the mounting process. They all agreed profession a true patient-specific anatomical articulator
that an error within a ±5-mm radius between the 2 axes (patent pending) for accurately replicating in 3D the
yielded clinically acceptable results that necessitated patient anatomy in its correct relationship and orienta-
minor occlusal adjustments.15,16,20-27 Nevertheless, it has tion. With this innovative device, all the aforementioned
been reported that the earbow transfer is not statistically procedures for accurately mounting the patient casts are
repeatable28 and that since different articulator systems eliminated, thus substantially diminishing potential er-
use different anterior third points of reference for their rors not only in mounting and articulator settings but,
earbow transfer, this may result in variation of the su- most importantly, also in dental prosthetic fabrication.
perior inferior position of the mounted casts on the ar-
ticulators, rendering the reliability of these anterior TECHNIQUE
reference points questionable.29
For that reason, the complex analog pantograph was 1. Import the patient’s cone beam computed to-
praised as a device that would accurately simulate the mography (CBCT) data, including the temporo-
patient’s border movements and transfer them onto a mandibular joints, and convert it into standard
fully adjustable articulator via its 6 tracings.30-32 Later, the tessellation language (STL) file format (InVesalius;
electronic pantograph was similarly reported to record CTI) (Fig. 1).
the condylar determinants with acceptable range. The 2. Use a point cloud processing software program
investigators highlighted the influence of correctly (3DReshaper; Hexagon Leica Geosystems) to clean
recording mandibular movements on the resultant the skull and enamel meshes and then enhance
occlusal morphology of posterior teeth, expressed in cusp and repair the anatomical features to be printed
angles and groove direction as a direct effect of variation (Fig. 2).

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Figure 2. Clean skull mesh. Figure 3. Whip Mix Corp 8500 series articulator imported.

Figure 4. A, Plane of articulator upper member extracted. B, Articulator upper member aligned to Frankfurt horizontal plane.

3. Import the digitized frame of the articulator (series related to the TMJs and their respective housing
8500; Whip Mix Corp) into the software program fossae, which are now replacing the articulator
(Fig. 3). frame parts (Fig. 8). This method of systematically
4. Extract the plane of the articulator and align it to merging and replacing the articulator frame seg-
coincide with the patient’s FHP by using the ments with the patient anatomy ensures accurate
porion and orbitale bony reference points (Fig. 4). and faithful replication of the patient condyles and
5. Explode the articulator parts from the compound fossae and relates all parts anatomically to each
mesh to remove unwanted segments before merg- other.
ing with the patient’s anatomical landmarks (Fig. 5). 9. Print the patient’s anatomical parts with a 3D
6. Because of the current limitations of the CBCT printer (M2; Carbon, Inc) in a rigid photopolymer
data, it is advisable to import a surface scan of the resin (Rigid Polyurethane, RPU 70; Carbon, Inc).
patient’s maxillary cast to provide clean features 10. Premount the postprocessed parts onto a modified
and more accurate surface representation by using articulator frame to render it anatomical (Fig. 9).
3Shape D1000 dental scanner with 3Shape Dental The maxillary printed model serves as a remount
System software (3Shape) (Fig. 6). index.
7. By using mesh registration algorithms, align the 11. Mount the patient mandibular cast to the supplied
maxillary surface scan with the tooth data of the maxillary index by using a traditional CR record
CBCT scan (Fig. 7). (Fig. 10A). The maxillary cast is then cross-
8. Thereafter, the maxillary anatomical landmarks, mounted by using the same CR record (Fig. 10B).
specifically teeth and/or ridges, are anatomically This eliminates the use of or need for an earbow

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Figure 5. A, Articulator parts exploded. B, Extra articulator parts removed.

transfer. Cross-mounting patient casts throughout

the course of the prosthodontic therapy is now
possible to facilitate prosthetic laboratory proced-
ures. The 3D-printed patient data, which
replicate both the condylar fossae and the actual
condyles at the correct intercondylar distance,
enable accurate generation of mandibular
movements.

DISCUSSION
Contemporary technology has presented new horizons
and endless possibilities. The luxury of being able to print
parts of the human anatomy without distortion, in
addition to them being anatomically related to one
another with extreme accuracy, is invaluable. The new Figure 6. Surface enamel scan and cone beam computed tomography
patient-specific anatomical articulator provides the scan imported
following extremely accurate features to simulate the
mandibular movements specific to every patient: the need for measuring it or relying on averages
(Fig. 9).
The condylar elements and the patient maxilla
Relating these anatomical features has been the essence Precise condylar pathways
of traditional facebow and earbow devices. It is not sur-
prising that this process is not followed by many practi- The shapes of the condyles and bony slopes (superior,
tioners, who find it to be quite challenging.22 With the backward, and medial) are obtained directly and pre-
current technology, this process is eliminated. The pa- cisely from the patient and not based on average values.
tient’s condyles and their respective fossae and the The standard procedure for setting the dental articu-
maxilla (whether dentulous or edentulous), which are all lator for optimal function is to use intraoral protrusive
anatomically related to each other, are printed in the and lateral records to set the horizontal and lateral
exact same relationship (Fig. 9). Additionally, they are condylar inclinations. This practice is eliminated
oriented to the FHP, eliminating potential mounting er- because the exact movement is reproduced and simu-
rors compared with conventional methods. This valuable lated based on the printed fossa contours for each
feature eliminates the need for earbow transfer (Fig. 11). condyle and its respective fossa. In fact, determining or
specifying a certain degree for condylar inclination is
Intercondylar distance not needed because there are no angles to adjust. The
Depending on the patient’s own anatomy, the inter- patient-specific inclinations are inherent in the printed
condylar distance is precisely reproduced, eliminating condylar parts (Fig. 11).

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Figure 7. A, Surface scan aligned to enamel CBCT scan. B, Alignment to main CBCT scan confirmed.

Figure 8. A, Maxillary reference model created and indexed to articulator. B, Parts reinforced as needed before printing.

Built-in immediate mandibular lateral translation

movement
By virtue of the printed anatomical features, whether this
movement truly exists or not, the patient anatomy would
reveal the true essence of this movement.41
An important procedure throughout complex pros-
thodontic rehabilitation treatments is the need to cross-
reference and remount patient casts for the purposes of
diagnostic waxing and fabrication of interim restorations.
The printed maxillary reference model (index) serves that
purpose. This printed model serves as the earbow record
for cross-mounting when needed and is related accu-
rately to the FHP and the condylar hinge axis (Figs. 9-12).
In summary, this new device is the first truly patient-
specific fully adjustable articulator and is more precise Figure 9. True anatomical relationship of condyles, fossae, and maxilla
and cost-effective than any pantographic tracing can maintained in exact same relationship as patient, eliminating need for
generate. It has been reported that the pantograph might earbow transfer.

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Figure 10. A, Patient mandibular cast mounted to printed maxillary index by using CR record. B, Patient maxillary cast cross-mounted to mandibular
cast by using same CR record. CR, centric relation.

Figure 11. A, Centric relation condylar position. B, Protrusive condylar inclination based on patient anatomy.

be used as a diagnostic instrument to compare and eval-

uate the degree of reproducibility of jaw movements in
relation to established norms and to assess the severity of
dysfunction based on tracings.32 The current device not
only is an excellent solution to fabricating complex pros-
thodontic prostheses but may also aid in the study and
diagnosis of anatomical relationships and pathways of
difficult treatments, as well as in the evaluation and diag-
nosis of patients with TMDs. This device, which simulates
patient-specific anatomy and mandibular movements,
could be included in a class of its own (class V) in the
articulator classification acknowledged by the ACP.
Limitations of this device are mainly related to the
currently available printing technology. Because of such
limitations, an assumption had to be made that the Figure 12. Full assembly of custom-printed anatomical structures
mandibular condyle and the articulating disc were always representing condylar elements and maxilla related to each other and to
synchronized and printed as 1-piece fused together. Addi- FHP from patient CBCT onto articulator frame (8500 series; Whip Mix
tionally, the printed material may fracture if not treated Corp). This patient-specific articulator requires no setting adjustments.

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