Keywords
Horizontal condylar guidance, Cone beam computed tomography, Lateral cephalogram, Panoramic radiograph, Protrusive occlusal record
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Luke AM, Kuriadom ST, George JM and Wahjuningrum DA. Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis [version 1; peer review: 1 approved]. F1000Research 2022, 11:105 (https://doi.org/10.12688/f1000research.75347.1)
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Systematic Review
Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis
[version 1; peer review: 1 approved]
PUBLISHED 27 Jan 2022
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding authors:
Alexander Maniangat Luke, Dian Agustin Wahjuningrum
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2022 Luke AM et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Luke AM, Kuriadom ST, George JM and Wahjuningrum DA. Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis [version 1; peer review: 1 approved]. F1000Research 2022, 11:105 (https://doi.org/10.12688/f1000research.75347.1)
First published: 27 Jan 2022, 11:105 (https://doi.org/10.12688/f1000research.75347.1)
Latest published: 27 Jan 2022, 11:105 (https://doi.org/10.12688/f1000research.75347.1)
Introduction
The registration of precise condylar path and mandibular movement on an articulator is critical to the achievement of an adequate oral rehabilitation of the patient. The inclination of the condylar trail, which is one of the five aspects of balanced occlusion, is therefore a crucial factor in prosthetic treatment success.1,2 This is the only aspect that is not under the control of a prosthodontist and should be reproduced precisely. Condylar guidance (CG) is described by the Glossary of Prosthodontic Terms 9 as mandibular guidance created by the condyle and articular disc crossing the shape of the articular eminence (AE).3 Horizontal condylar guidance (HCG) and lateral condylar guidance (LCG) are the two types of CG. The horizontal condylar route is the path of movement of the condyle-disk assembly in the joint cavity during a protrusive mandibular movement, whereas the lateral condylar path is the path of movement of the condyle-disk assembly in the joint cavity during a lateral mandibular movement.4 Ignorantly recorded condylar guidance will result in occlusal interferences during functional actions, increasing chair side time for prosthesis adjustment, which can be unpleasant for both the patient and the prosthodontist.5,6
Numerous strategies, such as interocclusal records, pantographic tracings, electronic jaw tracking devices, radiographic methods, and so on, can be used to determine horizontal condylar inclination, but programming a semi-adjustable articulator with a protrusive interocclusal record after training the patient to trace a gothic arch is still the most commonly used method in clinical practice.1 The accuracy of Gothic arch recording is influenced by factors such as the patient's neuromuscular control, the stability of the record base, and the recording media. Additionally, when the patient moves the jaw laterally during protrusion, the registration of the condylar route alters.7 Even semi-adjustable articulator setup with interocclusal records has a limited degree of repeatability and is susceptible to instrument, operator, and interocclusal record material factors.1
Radiographs can indeed show the shape of the articular eminence and the glenoid fossa of the temporal bone.8 Magnetic resonance imaging (MRI), cone-beam computed tomography (CBCT), computed tomography (CT), panoramic radiograph (OPG), and lateral cephalogram (LC) are currently accessible to visualise temporomandibular joint components.9 The primary advantages of these approaches are that measurements are based on stable bone landmarks and that mistakes caused by operator inexperience and insufficient neuromuscular control of the patient may be prevented.10,11
Panoramic radiography produces a two-dimensional (2D) image of the temporomandibular joint (TMJ) with a flat reflection of the curved surface of the maxilla and a composite image of the tissues in the X-ray's route but it is frequently inaccurate for measuring HCG due to multiple structures being superimposed,9 whereas 3D multiplanar sections acquired from a CBCT scan give a better anatomic perspective of the condyle and its route without the superimpositions shown in 2D radiography images.11,12 Magnetic resonance imaging (MRI) is a thorough examination that is considered in the literature to be the “gold standard” in diagnosing TMJ disorders; nevertheless, it is not often utilised in everyday dentistry practice due to financial constraints.9
The primary disadvantages to the widespread use of these radiography techniques are the high cost of equipment, discomfort, and radiation exposure to patients.13 In the study conducted by Tannamala et al,14 a difference of 2-4 degrees in HCG angle between OPG and the protrusive occlusal record was found while in the study by Shreshta et al,13 a difference of 9-10 degrees in HCG angle between CBCT images and the protrusive occlusal record was observed whereas in the study by Das et al11 no significant difference between in HCG angle between CBCT images and the protrusive occlusal record was observed. Additionally, there is no agreement on the findings of several methods for determining the HCG angle and whether approach, clinical or radiographic, offers the most accurate HCG angle readings. There is still no research that have given a complete, quantitative study on which diagnostic reasoning may be based. As a result, the purpose of this systematic review and meta-analysis was to examine and evaluate the accuracy of radiographic and protrusive occlusal record (POR) techniques in estimating horizontal condylar guidance (HCG) angles in dentate and edentulous patients.
Methods
Protocol and registration
Our systematic review and meta-analysis was registered in PROSPERO (CRD42020206599) on the 28th September 2020, and it was undertaken and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.15,55
Focused research question
In the Patient, Intervention, Comparison, and Outcome (PICO) design, the following focused question was proposed: “Is there a difference in the accuracy of radiographic and protrusive occlusal record techniques in estimating condylar guiding angles in dentate and edentulous patients?”
Search strategy
To obtain papers in the English language, a complete electronic search was conducted the databases PubMed/ MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science from 1st January 2011 till 31st December 2020. The distinct electronic search of the journals listed in Table 1 was carried out. Google Scholar, Greylit, and OpenGrey were used to conduct searches in the clinical trials database, cross-referencing, and Grey literature.
Table 1. Search method, study design (PICOS; Patient, Intervention, Comparison, and Outcome) tool, and the journals included in the comparison.
For searching articles, Medical Subject Headings (MeSH) terms, keywords, and other free phrases were coupled using Boolean operators (OR, AND). Following the syntactic guidelines of each database, the same terms were utilised across all search platforms. Table 1 shows the search method as well as the population, interventions, comparisons, outcomes, and study design (PICOS) tool.
Inclusion criteria outline according to the PICOS strategy
Population (P): Condylar guiding angles were determined in dentulous/partially edentulous and totally edentulous patients who were free of temporomandibular disorders. Dentulous patients with almost complete set of teeth or with partial edentulousness and nearly ideal occlusion with Class 1 molar relationship and aged 18 years and above, as well as completely edentulous patients with well-formed ridges, good neuromuscular control, adequate inter-maxillary space, and orthognathic jaw relation.
Interventions (I): Studies assessing radiographic techniques like cone beam computed tomography (CBCT), orthopantomogram (OPG), lateral cephalograms, computerized tomography (CT) scan and temporomandibular joint (TMJ) tomogram for determining accurate measurements of condylar inclination.
Comparison (C): Studies assessing clinical techniques like protrusive occlusal wax record, for determining accurate measurements of condylar inclination
Outcome (O): Condylar guidance angles using different methods irrespective of the methods of quantifying the outcomes.
Study design (S): Clinical trials, in vivo studies, randomised controlled trials, non-randomised control trials, quasi experimental investigation, before and after research design, and cohort studies comparing radiographic and clinical techniques.
Exclusion criteria
The following studies were excluded:
1. Non-clinical studies, in-vitro studies, and animal studies. Furthermore, studies that reported on a single intervention were discarded.
2. Studies on patients with TMJ problems, defective restorations, periodontal disease, excessive attrition, and impaired neuromuscular control.
3. Studies not fully available in the database.
4. Article reporting only abstracts were also excluded.
5. Case series, case reports, reviews, and in vitro research were also eliminated.
Screening process
Two review authors (A.M.L. and S.T.K.) conducted the search and screening in accordance with the previously defined procedure. After the initial retrieval, duplicates were removed and the titles and abstract of all the results were screened by 2 authors (A.M.L. and A.M.P). Full text publication articles were retrieved for those articles that met the eligibility criteria. The list of excluded articles at the initial retrieval was crosschecked by all the authors and disagreements were resolved by discussing amongst all. The entire papers were evaluated in the second phase, and papers that did not fulfil the inclusion requirements were unanimously discarded. Cohen's kappa (k) determined the degree of agreement between the two reviewers to be 0.90 for titles and abstracts and 0.92 for full-texts. After discussion, the third author (S.M.) settled the disagreements among the authors/reviewers. Some studies included both ‘dentulous’ and ‘edentulous’ patients. If the findings for the subset of teeth fulfilling the qualifying criteria were available in such studies, that subset of teeth was included in the current review. The study was discarded if it was not possible to split the study findings into two groups. The authors of the listed papers were contacted via email to clarify any concerns or missing data.
Data extraction
The following data were extracted from the included studies by two independent reviewing authors (D.A.W. and J.M.G.) using pilot tested customised data extraction forms: study identification number, place of study, sample size, age of patient, articulator model, make of machine, radiographic techniques, outcome measures, author’s conclusions.
Assessments of the risk of bias and quality
To assess the risk of bias and methodological quality of the included articles, a simplified version of the NIH (National Institutes of Health) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies16 was used, as they reported the results of cross-sectional studies. The assessment “Cannot Determine” (CD) was recorded for the element of the questionnaire for which no information was available in the text. Consistency of studies scoring five or more “Yes” out of eight was rated “Good,” consistency of studies scoring three to five “Yes” was considered “Fair,” and consistency of studies scoring fewer than three “Yes” was labelled “Poor”.17
Quantitative synthesis
For statistical analysis, Review Manager (RevMan) 5.3 was utilised. The pooled results for dichotomous data were presented as relative risks (RRs) at 95 % confidence intervals (CIs), with P<0.05 deemed significant. The I2 test at α = 0.10 was used to measure statistical heterogeneity. For I2>50% and P≤0.10, subgroup analysis was performed. The random-effects model was used when I2 was more than 50%. To determine the stability of the data, sensitivity analysis was performed. Funnel plots were used to detect publication bias in research with more than ten trials for each outcome evaluated.18
Results
Literature search
The preliminary electronic database search yielded 225 titles (PubMed/MEDLINE and Cochrane library) and 778 titles (Google Scholar); hand scanning the reference lists of the selected studies yielded no further articles. After removing duplicates, there were 563 titles left. Out of these 563 articles, 515 were removed at the initial screening after reading the titles and abstracts. Further to the reviewers' analysis and discussions, 48 papers were chosen for full-text evaluation. Following pre-screening, implementation of the inclusion and exclusion criteria, and maintaining of the PICOS questions, 33 studies remained (10 with inappropriate study design, 3 with inappropriate comparison group, and two studies evaluated lateral condylar guidance) and were included in the qualitative analysis, whereas 32 studies were included in the quantitative synthesis. A flowchart of the search results is represented in Figure 1.
Figure 1. PRISMA flow diagram.
Study characteristics
The general characteristics of 33 studies1,7–9,11,13,14,19–44 are summarized in Table 2. All included studies were unicentric trials published between 2011 and 2020. Typically, 26 studies were conducted in India,1,7,11,13,14,19,20,23–27,29,30,32,34–44 two each in Iran8,28 and Saudi Arabia22,33 and one each in Nepal,21 Korea31 and Poland.9 In total, 20 studies included were conducted among dentate patients having a total sample size of 595 and age ranged from 18–43 years1,19,20,21,25,27,30,32,34,37–40,42,44 while 15 studies included were conducted among edentulous patients having a total sample size of 277 and age ranged from 35–75 years.7–9,11,13,14,19,20,22–24,26,28,29,31,33,35,36,41,43 The ethical approval was obtained in 25 studies1,9,11,13,14,19–26,30–36,38,40–43 while informed consent was obtained in only 20 studies.8,9,11,20–26,30,33,35–38,40–43 The funding information was mentioned in only two studies by Godavarthi et al7 and Naqash et al.33 Out the 33 included studies, only 6 studies,11,25,28,35,37,38 have mentioned about the sample size estimation. The brands and the models of the articulator, OPG, CBCT, CT scan, LC and TMJ tomogram varied according to the studies. Radiographically the HCG angle was measured using OPG1,7–9,14,19–23,26–28,30–32,34–40,42 in 24 studies, seven studies recorded HCG angle with CBCT,8,11,25,31,33,35,43 five studies used LC1,23,24,29,41 and one study each recorded HCG angle with CT scan13 and TMJ tomogram.44 For all of the included studies, the orientation jaw relation was registered utilising face-bow and was transferred on to the semi-adjustable articulator employing mounting jig or extra oral gothic arch tracers, and the protrusive interocclusal record was obtained by instructing the subject to protrude the mandible forward by 6mm. The condylar guidance angle was measured between the Frankfort's horizontal plane and the line formed along the posterior slope of articular eminence (AE), connecting the most concave (highest) point on the glenoid fossa and the most convex (lowest) point on the apical portion of AE in all the included studies. The right and left HCG angle was calculated separately for both the dentate and edentulous patients in all the included studies except for studies Amin et al,20 Jerath S et al,25 Katiyar et al26 and Paul et al1 cumulative value of right and left angle is mentioned.
Table 2. Characteristics of the included studies.
| Study ID | Place of study | Sample size D/E | Age group | Articulator model | Make of machine | Radiographic techniques | Dentulous/Edentulous | Author’s conclusions | ||
|---|---|---|---|---|---|---|---|---|---|---|
| Right I/C/r | Left I/C/r | Both I/C/r | ||||||||
| Acharya S et al 201519 | India | 20 D 20 E | 18-30 years 45-75 years | HANAU articulator modelWide-Vue, U.S.A. | Orthoralix 9200; Gendex Dental Systems, Milan, Italy) | OPG | Dentulous 35.8/33.75/0.57 Edentulous 30.35/26.5/0.57 | Dentulous 34.05/34.25/0.55 Edentulous 29.50/26.75/0.72 | Measurement of condylar inclination angles using panoramic radiographs gave higher values, as compared to the inter-occlusal record method. | |
| Amin B et al 201820 | India | 30 D 30 E | 40-60 years | Hanau Wide-Vue | Orthophos XG | OPG | Dentulous 35.53(6.248)/30.83(5.384) Edentulous 29.10(9.135)/24.20(7.066) | The use of OPG to set condylar guidance on the articulator should be taken into consideration for both dentulous and edentulous subjects | ||
| Bhandari A et al 201821 | Nepal | 25 E | HanauTM Wide-Vue Articulator, Whip Mix Corporation, USA) | Orthoralix 9200 DDE Gendex, U.S.A. | OPG | 24.0(6.24)/21.3(5.31)/0.643 | 24.48(4.96)/21.08(5.55)/0.622 | The panoramic radiographic tracing can be used to calculate the mean horizontal condylar guidance in the completely edentulous patients | ||
| Das A et al 202011 | India | 40 D | 20-40 years | Hanau Wide- Vue; Whip Mix Corp | Carestream Kodak 9300C; Kodak | CBCT | 35.43(3.13)/32.78(2.64)/0.95 | 35.18(2.62)/32.9(2.49)/0.95 | CBCT can be used to obtain the sagittal horizontal guidance for programming semi adjustable and fully adjustable articulators | |
| Dewan H et al 201922 | Saudi Arabia | 30 D | 20–40 years | Whipmix 2240 series (Louisville, USA) | Model orthorelix DDE; Gendex, USA | OPG | 42.57(7.60)/36.37(9.42)/0.658 | 42.71(7.84)/35.85(6.87)/0.537 | OPG could be used as an alternative to clinical methods to overcome the disadvantages associated with conventional techniques. | |
| Galagali G et al 201623 | India | 120 D | 20–40 years | HANAUTM Wide-Vue, Whip Mix Corporation, USA | OPG LC | 34.83(6.44)/34.03(6.63)/34.16(6.83) | 35.7(6.5)/35.16(5.85)/34.16(6.83) | The correlation between protrusive interocclusal records and the lateral cephalogram radiograph tracings which were more positively related than the panoramic radiograph. | ||
| Godavarthi AS et al 20157 | India | 20 D 20 E | 20-30 years 40-65 years | Hanau wide Vue-II | Dentsply Gendexorthoralix 9200 | OPG | Dentulous 37.10(5.902)/40.55(6.669)/0.677 Edentulous 36.10(5.543)/36.70(4.846)/0.473 | Dentulous 34.75(4.506)/40.15(4.246)/0.736 Edentulous 33.60(4.860)/35.95(4.261)/0.329 | Panoramic radiograph can be used as an alternative to interocclusal technique only in edentulous patients. | |
| Goyal MK et al 201124 | India | 20 D | 19-35 years | Hanau wide-Vue | Kodak 8000 C unit | LC | 36.05(7.54)/32.75(6.17) | 36.05(7.54)/34.75(7.69) | No significant difference found in mean sagittal condylar values obtained from arcon articulator and cephalometric tracings indicates replication of sagittal condylar guidance value from image of articular eminence. | |
| Jerath S et al 201925 | India | 15 E | 45-70 years | Hanau wide Vue | Newtom Giano, Italy | CBCT | 33.09(4.65)/26.80(2.14) | 33.81(3.45)/27.00(2.23) | 33.45(4.04)/26.90(2.19) | Highest value of horizontal condylar guidance angulation was obtained by CBCT, lowest was obtained by interocclusal wax records. |
| Katiyar P et al 201826 | India | 20 D | 20-30 years | Hanau articulator Wide-Vue, Teledyne/Water Pik, Fort Collins, CO | Satelac X Mind Pano ceph digital x-ray machine | OPG | 34.80(12.697)/34.05(14.16)/0.132 | 36.95(11.30)/37.35(14.13)/0.18 | 35.88(11.916)/35.70(14.06)0.163 | Considering the inaccuracies of the interocclusal record technique, the alternative method of recording protrusive condylar guidance angle by panoramic radiograph is not difficult to perform and appears to have useful clinical application. |
| Khalikar S et al 201727 | India | 10 E | 50-60 years | Hanau wide vue articulator | OPG | 25.8(4.26)/29.5(4.7) | 26.0(4)/31.0(3.29) | OPG and protrusive records may be used as a reliable guide for measuring condylar guidance angulation. | ||
| Kharzinejad A et al 201828 | Iran | 42 D | Cranex D Finland-hinisilky | OPG | 35.88(3.27)/33.9(3.19)/0.81 | 35.93(3.27)/33.78(3.22)/0.83 | There was significant difference in the difference between the condylar slope in panoramic radiography and the interocclusal records in the right and left sides. | |||
| Kumar KR et al 201729 | India | 20 D | 20-35 years | Kodak 8000C | LC | 35.22(1.42)/35.85(1.38) | 34.51(1.56)/35.85(1.38) | The mean difference in the sagittal condylar guidance values of an arcon articulator and lateral cephalogram is non-significant on right side and highly significant on left side. | ||
| Kumari VV et al 201630 | India | 10 E | 50-65 years | Hanau wide Vue semi-adjustable articulator | OPG | 37.10(8.26)/25.7(3.4) | 38.0(9.56)/25.40(3.59) | A definite difference was found between the condylar guidance values obtained by the OPG and the most commonly used extraoral gothic arch tracing method in edentulous patients. | ||
| Kwon OK et al 201731 | Korea | 20 D | 20-40 years | Kodak CS 9000; Carestream Dental, Sydney, Australia Kavo Dental, Biberach, Germany | OPG CBCT | 38.9(9.0)/ 35.3 (8.1)/30.1(6.7)/0.834/0.845 | 38.7(6.4)/36.1(6.3)/30.2(6.3)/0.918/0.791 | Strong correlations were detected between the SCGAs obtained using radiographic images and the protrusive occlusal record. | ||
| Loster JE et al 20179 | Poland | 10 D | 18 years + | OPG | 65.92(8.01) | 64.83(5.81) | In young, healthy patients without clinical symptoms of TMJ dysfunction the functional OPG images should not be compared with the range of the mandibular opening. | |||
| Mittal S et at 202032 | India | 15 E | 45-65 years | Hanau articulator model Wide-Vue, U.S.A | OPG | 33.27(5.43)/35.0(4.98)/0.719 | 30.93(4.90)/30.07(5.13)/0.622 | Panoramic radiographs can be considered as a reliable aid to calculate horizontal condylar guidance for programming of semi adjustable articulator. | ||
| Naqash TA et al 202033 | Saudi Arabia | 23 D | 18-30 years | Denar Mark II articulator (Whip Mix Corporation, USA | KaVo 3D eXam; Kavo Dental, Germany | CBCT | 38.12(4.81)/31.82(4.53)/0.874 | 38.96(4.19)/32.14(4.32)/0.842 | Strong correlations were found between SCGAs obtained using PR, and CBCT techniques. CBCT values were 6°–7° higher than those obtained using the protrusive occlusal records. | |
| Patil R et at 201534 | India | 10 E | HanauTM Wide-Vue articulator (Whip Mix Corporation) | Kodak 8000c, France | OPG | 17.00(3.432)/18.50(4.11)/0.53 | 17.30(4.739)/20.00(4.08)/0.55 | Gothic arch tracing gave quite similar readings as suggested by the radiographic landmarks and can be continued as a successful clinical method. | ||
| Paul R et al 20181 | India | 20 E | 45-75 years | Hanau™ Wide-Vue Articulator (Whip Mix Corporation, USA | X-Mind Pano D+, Satelec, Acteon group, Thailand, Bangkok | OPG LC | 35.60(4.97/38.95(4.77)/28.35(5.62)/0.94/0.89 | 34.80(5.17)/38.95(4.77)/28.00(6.8518)/0.93 | 35.20(4.94)/38.95(4.77)/28.17(5.99)/0.94 | HCG values from cephalometric tracing of diagnostic radiographs can be used as an adjunct to the clinical method but cannot be used independently for programming a semi-adjustable articulator. |
| Prakash SS et al 201935 | India | 25 D | 18-30 years | HANAU Wide – Vue Articulator, Whip Mix Corporation, USA | SIRONA Germany Newtom, Italy | OPG CBCT | 35.85(4.21)/30.96(4.70)/29.80(4.44) 0.97/0.958 | 35.964.23)/31.13(4.22)/29.80(4.44)/0.970/0.979 | Between radiographic techniques, OPG showed higher HCI values than CBCT. | |
| Prasad KD 201236 | India | 75 D | 20-40 years | HANAU Wide-Vue Articulator,Whip Mix Corporation, USA | OPG | 36.68(4.69)/34.71(5.27)/0.413 | 38.18(5.22)/35.00(4.85)/0.291 | Interocclusal record technique with inherent errors of up to 30°; the radiographic method may have clinical relevance. | ||
| Salemi F et al 20178 | Iran | 28 D | 13-43 years | SCARA II, Planmeca, Helsinki, Finland New Tom 3G (Quantitative Radiology, Verona, Italy | OPG CBCT | 35.43(30)/33.49(2.94)/32.60(3.08) | 35.67(3.36)/33.94(3.40)/32.92(3.16) | CBCT and Panoramic can be used instead of interocclusal record for adjusting condylar guidance in articulator, if necessary. | ||
| Shah K et al 201437 | India | 24 E | Hanau Wide Vue | OPG | 38.54(4.18)/30.42(6.06)/-0.078 | 41.88(5.69)/32.38(8.55)/-0.109 | Condylar guidance values obtained from the radiographs were higher than those obtained at the stage of jaw relation recording stage. | |||
| Shah RJ et al 201338 | India | 20 E | 40-60 years | Hanau Wide Vue | OPG | 37.9(3.89)/35.45(4.69) | 38.9(5.22)/37.35(5.17) | No significant difference found in mean sagittal condylar values obtained from Hanau Wide Vue Articulator and OPG tracings indicates replication of sagittal condylar guidance values from image of articular eminence. | ||
| Shetty S et al 201839 | India | 12 E | Hanau Wide-Vue | OPG | 29.483(4.64)/26.33(3.75) | 28.77(5.2)/26.67(3.172) | Correlation exists between the condylar guidance angles obtained by radiographic method and intraoral gothic arch tracing method. | |||
| Shetty S et al 201340 | India | 15 E | Hanau Wide Vue | OPG | 37.13(5.40)/12.73(11.08) | 35.13(4.79)/13.47(9.87) | The condylar guidance value/angle obtained from the radiographs was higher than those obtained during jaw relation and try-in. | |||
| Shreshta P et al 201213 | India | 12 D | 20-40 years | Protar 7, KaVo Dental GmbH, Bismarckring, Biberach | Somaton Sensation 40, Siemens Erlanger Germany | CT scan | 43.83(6.57)/33.33(7.75)/0.423 | 42.42(6.06)/33.64(7.94)/0.237 | The right and left HCG values were almost similar. The CT scan showed higher HCG values than the clinical methods | |
| Singh S et al 201741 | India | 10 D | 20-40 years | LC | 34.10(6.41)/31.30(7.31)/0.79 | 34.10(6.41)/31.80(6.44)/0.90 | Radiographic method can be used to yield consistent HCG; however, the protrusive method should be employed. | |||
| Sirana P et al 201842 | India | 20 E | 35-60 years | Hanau Wide-Vue semi-adjustable articulator | OPG | 29.35(4.58)/26.84(3.69) | 27.54(5.01)/25.15(3.24) | There was correlation between sagittal condylar guidance obtained by both intraoral gothic arch method as well as radiographic method done on digital panoramic radiographs. | ||
| Tannamala PK et al 201214 | India | 10 D | Hanau articulator ModelWide-Vue 183 | Planmeca Promax; Helsinki, Finland | OPG | 36.50(3.75)/32.80(5.01) | 35.50(4.35)/32.10(5.9) | The protrusive condylar guidance angles obtained by panoramic radiograph may be used in programming semi-adjustable articulators. | ||
| Vadodaria J 201543 | India | 30 D | 24-40 years | Hanau Wide Vi | CBCT | 39.63(1.96)/27.43(2.61)/0.08 | 40.50(2.70)/28.75(3.01)/0.10 | CBCT presents with highest mean condylar guidance values when compared with all three clinical methods. | ||
| Venkateshwaran R et al 201444 | India | 21 E | TMJ tomogram | 30.47(7.89)/25.23(9.41)/0.78 | 30.47(8.35)/25.71(10.15)/0.74 | The articular eminence traced on a TMJ tomogram image represents the horizontal condylar inclination with a mean difference of 5° in 21 subjects evaluated. | ||||
Assessment of risk of bias
The included studies' quality evaluation revealed a wide range of results. Table 3 shows the assessment of the risk of bias for the included studies. Out of the 33 studies, only seven studies were rated as good quality studies,8,11,25,28,35,37,39 whereas the remaining 26 studies were rated as fair quality studies.1,7,9,13,14,19–24,26,27,29–34,36,38,40–44 This fair quality was basically due to no justification of sample size, no assessor blinding and no mention about participation rate and confounder blinding.
Table 3. Methodological quality appraisal of included studies.
| Study ID | Objective clearly stated? | Study population clearly defined? | Participation rate at least 50%? | Subjects comparable? | Justification of sample size? | Reliability of outcome measures? | Assessors blinding? | Adjustment for confounders? | Quality of Studies |
|---|---|---|---|---|---|---|---|---|---|
| Acharya S et al 201519 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Amin B et al 201820 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Bhandari A et al 201821 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Das A et al 202011 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Dewan H et al 201922 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Galagali G et al 201623 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Godavarthi AS et al 20157 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Goyal MK et al 201124 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Jerath S et al 201925 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Katiyar P et al 201826 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Khalikar S et al 201727 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Kharzinejad A et al 201828 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Kumar KR et al 201729 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Kumari VV et al 201630 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Kwon OK et al 201731 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Loster JE et al 20179 | Yes | Yes | No | Yes | No | Yes | Yes | No | Fair |
| Mittal S et at 202032 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Naqash TA et al 202033 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Patil R et at 201534 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Paul R et al 20181 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Prakash SS et al 201935 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Prasad KD 201236 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Salemi F et al 20178 | Yes | Yes | No | Yes | No | Yes | Yes | No | Good |
| Shah K et al 201437 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Shah RJ et al 201338 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Shetty S et al 201839 | Yes | Yes | No | Yes | Yes | Yes | No | No | Good |
| Shetty S et al 201340 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Shreshta P et al 201213 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Singh S et al 201741 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Sirana P et al 201842 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Tannamala PK et al 201214 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Vadodaria J 201543 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
| Venkateshwaran R et al 201444 | Yes | Yes | No | Yes | No | Yes | No | No | Fair |
Synthesis of results
A final tally of 32 papers1,7,8,11,13,14,19–44 met the quantitative analysis inclusion criteria. Following that, four independent meta-analyses were done to assess the right and left HCG angle in dentate and edentulous patients.
HCG angle of right side for dentate patients
The pooled outcomes from 16 studies,8,11,13,14,22–24,26,28,29,31,33,35,36,41,43 with a total sample size of 738 each in the radiographic and POR group, the standardized mean difference (SMD) value for HCG angle using random effect model was 0.68 [0.37, 0.98] and showed a statistically significant difference (P<0.0001) between the radiographic and POR group [Tau2=0.41, Chi2=145.77, I2=86%], (Figure 2). After subgroup analysis was performed using a random-effect model, it was discovered that for the CBCT method,8,11,31,33,35,43 there was a statistically significant difference favouring the radiographic method (SMD, 1.35; 95% CI: 0.41–2.30; P<0.00001) with 93% heterogeneity. For OPG method,8,14,22,23,26,28,31,35,36 radiographic method showed a statistically significant difference as compared to POR method (SMD, 0.52; 95% CI: 0.22–0.83; P=0.0009) with 74% heterogeneity. LC method23,24,29,41 showed no statistically significant difference between the radiographic and POR group (SMD, 0.04; 95% CI: -0.30–0.39; P=0.80) with the heterogeneity of 38%. CT scan method13 showed a statistically significant difference between the radiographic and POR method (SMD, 1.41; 95% CI: 0.50–2.32; P=0.002) (Figure 2).
Figure 2. Forest plot of the pooled analysis and the subgroup analysis comparing radiographic techniques and protrusive occlusal records for right side horizontal condylar guidance angle in dentulous patients.
SD - standard deviation, IV - inverse variance, CI - confidence interval.
HCG angle of left side for dentate patients
The pooled outcomes from 16 studies,8,11,13,14,22–24,26,28,29,31,33,35,36,41,43 with total sample size of 738 each in the radiographic and POR group, the standardized mean difference (SMD) value for HCG angle using random effect model was 0.63 [0.32, 0.95] and showed a statistically significant difference (P=0.008) between the radiographic and POR group [Tau2=0.43, Chi2=151.64, I2=87%], (Figure 3). After subgroup analysis was performed using a random-effect model, it was discovered that for the CBCT method,8,11,31,33,35,43 there was a statistically significant difference favouring the radiographic method (SMD, 1.29; 95% CI: 0.44–2.13; P=0.03) with 94% heterogeneity. For OPG method,8,14,22,23,26,28,31,35,36 radiographic method showed a statistically significant difference as compared to POR method (SMD, 0.51; 95% CI: 0.14–0.87; P=0.006) with 82% heterogeneity. LC method23,24,29,41 showed no statistically significant difference between the radiographic and POR group (SMD, -0.05; 95% CI: -0.54–0.44; P=0.84) with the heterogeneity of 67%. CT scan method13 showed a statistically significant difference.
Figure 3. Forest plot of the pooled analysis and the subgroup analysis comparing radiographic techniques and protrusive occlusal records for left side horizontal condylar guidance angle in dentulous patients.
SD - standard deviation, IV - inverse variance, CI - confidence interval.
HCG angle of right side for edentulous patients
The pooled outcomes from 14 studies,1,7,21,25,27,30,32,34,37–40,42,44 with total sample size of 257 and 237 in the radiographic and POR group, respectively, the standardised mean difference (SMD) value for HCG angle using random effect model was 0.82 [0.34, 1.29] and showed a statistically significant difference (P=0.0008) between the radiographic and POR group [Tau2 =0.68, Chi2 =75.09, I2 = 83%] (Figure 4). After subgroup analysis was done using a random-effect model, it was shown that the CBCT method25 had a statistically significant difference favouring the radiography technique (SMD, 1.69; 95% CI: 0.84–2.54; P<0.0001). For OPG method,1,7,21,27,30,32,34,37–40,42 radiographic method showed a statistically significant difference as compared to POR method (SMD, 0.65; 95% CI: 0.11–1.20; P=0.02) with 83% heterogeneity. LC method1 showed a statistically significant difference between the radiographic and POR group (SMD, 1.99; 95% CI: 1.22–2.77; P<0.00001). TMJ tomogram method44 did not show a statistically significant difference between the radiographic and POR method (SMD, 0.59; 95% CI: 0.34–1.29; P=0.06) (Figure 4).
Figure 4. Forest plot of the pooled analysis and the subgroup analysis comparing radiographic techniques and protrusive occlusal records for right side horizontal condylar guidance angle in edentulous patients.
SD - standard deviation, IV - inverse variance, CI - confidence interval.
HCG angle of left side for edentulous patients
The pooled outcomes from 14 studies,1,7,21,25,27,30,32,34,37–40,42,44 with total sample size of 257 and 237 in the radiographic and POR group, respectively, the standardized mean difference (SMD) value for HCG angle using random effect model was 0.66 [0.18, 1.15] and showed a statistically significant difference (P=0.007) between the radiographic and POR group [Tau2 =0.67, Chi2 =77.39, I2=83%] (Figure 5). After subgroup analysis was done using a random-effect model, it was discovered that for the CBCT technique,25 there was a statistically significant difference favouring the radiography method (SMD, 2.28; 95% CI: 1.33–3.23; P<0.00001). For OPG method,1,7,21,27,30,32,34,37–40,42 radiographic method showed a statistically significant difference as compared to POR method (SMD, 0.55; 95% CI: -0.02–1.13; P=0.06) with 85% heterogeneity. LC method1 did not show a statistically significant difference between the radiographic and POR group (SMD, 0.50; 95% CI: -0.13–1.13; P=0.12). TMJ tomogram method44 did not show a statistically significant difference between the radiographic and POR method (SMD, 0.59; 95% CI: -0.03–1.21; P=0.06) (Figure 5).
Figure 5. Forest plot of the pooled analysis and the subgroup analysis comparing radiographic techniques and protrusive occlusal records for left side horizontal condylar guidance angle in edentulous patients.
SD - standard deviation, IV - inverse variance, CI - confidence interval.
Sensitivity analysis
Table 4 presents the results of sensitivity analysis of the right and left HCG angle for the dentate and edentulous patients. Studies of fair quality1,7,9,13,14,19–24,26,27,29–34,36,38,40–44 or good quality8,11,25,28,35,37,39 were excluded from sensitivity analysis. After excluding these studies, the HCG angle values for the right and left sides of dentate patients, as well as the right side of edentulous patients, did not show a significant difference when comparing the radiographic and POR groups, with the exception of the left HCG angle values in edentulous patients, which showed an adverse change. A reanalysis using the fixed-effect model revealed that the results were not unfavourable. Excluding subgroups from a single research did not result in a substantial improvement in the SMD of HCG levels. Also, the inclusion of single radiographic technique of only CBCT and only OPG showed that the outcomes were not adverse whereas when inclusion of only LC was considered no statistically significant difference was found between the radiographic and protrusive occlusal record group for the HCG value of right and left side for dentate patients (Table 4).
Table 4. Sensitivity and subgroup analysis of the outcomes between radiographic techniques and protrusive occlusal record group for dentulous and edentulous patients.
Publication bias
Figure 6 represents the funnel plot comparing horizontal condylar guidance angle between radiographic techniques and protrusive occlusal records for HCG angle values of right and left side for dentate and edentulous patients resemble a symmetrical (inverted) funnel indicating lack of publication bias.
Figure 6. Funnel plot for horizontal condylar guidance angle, A: Right side dentulous patients, B: Left side dentulous patients, C: Right side edentulous patients, D: Left side edentulous patient.
CT - Computed tomography, SE - Standard error, SMD- Standardized mean difference, TMJ - Temporo-mandibular joint.
Discussion
The route followed by the condyle with reference to the articular eminence when the mandible advances protrusively or laterally from centric relation is referred to as the condylar path.45 It is an essential regulating element since it impacts mandibular motions and is unique to each patient.19
Prosthodontics considers an equivalent of condylar guiding on an articulator to be an essential requirement.46 Articulators are utilised to imitate the patient's interocclusal positioning and certain mandibular motions. The sophistication and adaptability of the articulator determine the precision with which mandibular motions are reproduced. Using proper technique, the semi-adjustable articulator is capable of replicating specific points on the path of the condyle during a protrusive movement, when set with an interocclusal positional record.47
Because condylar inclination values obtained with various planes of reference cannot be compared,48 the plane of reference is an important element to consider. As a result, the radiological pictures give sagittal reconstructions of the skeletal components, and the contour of the articular eminence may be utilised to help in establishing the condylar guiding inclination of a semi-adjustable articulator.19
As a result, the goal of this study was to compare the condylar guidance values acquired by tracing radiography pictures to those produced by interocclusal protrusive recordings of dentulous and edentulous patients. The values of horizontal condylar inclination vary with age, gender, and ethnicity. This review included 33 studies published from 2011 to 2020 conducted in various countries which directly compared both the techniques. The age of the included dentate and edentulous patients ranged 18-43 years and 35–75 years, respectively. In completely edentulous patients, condylar paths are determined by the following factors: the bony fossae, tone of the muscles responsible for mandibular movements and their nerve controls, limitations imposed by the attached ligaments, shape and movements of the menisci while in dentate patients during protrusive movement, as the mandible moves forward there is an influence of the anterior guidance which affects the exact path of the condyle, hence separate analysis of dentate and edentulous patients was conducted.49 Hence, the results of this systematic review can be applicable to a varied population range and also in conditions as close as possible to those observed in daily clinical practice.
The overall results of the present systematic review and meta-analysis indicated that the HCG angle values of the right and left side showed a statistically significant difference favouring the radiographic method as compared to POR for dentate as well as edentulous patients. The sub-group analysis showed that for CBCT and OPG images the SMD of HCG angle values for dentate and edentulous patients on right side and left side showed a statistically significant difference as compared to the POR method except for edentulous patients the left side HCG angle values did not show a statistically significant difference between the two groups, whereas for LC images the SMD of HCG angle values of right and left side did not show a statistically significant difference between the two groups, except in edentulous patients right side HCG angle values showed a significant difference between the two groups.
The methodologies applied in the studies differed considerably. In the clinical method, the protrusive jaw relation is used to set the condylar elements of the articulator so they will reproduce inclinations, which are exact or nearer to the patient’s temporomandibular articulation. In the included studies interocclusal protrusive wax records, Lucia jig and gothic arch tracers have been used in setting the condylar guidance in semi-adjustable articulators. As the HCG changes with amount of protrusion, for studies where protrusive wax records were used the amount of protrusion was kept same for all the patients at 6 mm and the same protrusive records were used for programming the articulator so it is important to keep the distance of protrusion the same.20,50 Once the protrusive jaw relation is established, the majority of research employed a Hanua Wide-vue semi adjustable articulator, while a few studies used a whip mix semi adjustable articulator to measure horizontal condylar inclination. The reference plane is used to calculate horizontal condylar inclination. Hanua articulators generate more precise angles since they mount the cast in reference to the Frankfort horizontal plane, whereas whip mix employs the nasion-porion plane as a reference plane.35,51 POR technique for measuring SCGAs, regardless of the material used, is inconsistent, lacks precision and has lower levels of reproducibility because of significant differences between the instruments,31,33 deformation or compression of the records, cast tipping due to improper adaptation of casts, force applied by the operator on record,32 changes in values with the degree of protrusion, the amount of overjet and overbite.1,8,33 Also, semi-adjustable articulators are unable to reconstruct the condylar movements adequately because of their fixed inter-condylar distance and straight condylar pathway.33 Christensen et al. demonstrated that radiographically measured condylar angles yielded higher values than intraoral recording techniques. The rigid mechanical principles controlling the motions of an adjustable articulator appear to be inapplicable to man's dynamic mandibular locomotor system.19,52
Panoramic radiography, lateral cephalogram and CBCT are now widely used in diagnoses. Significantly higher condylar guidance angle values in panoramic radiograph as compared to protrusive interocclusal record are reported for this review. The review's results might be supported for any of the following basis. First, the panoramic radiography technique often yields a larger value than the actual, as demonstrated by Gilboa et al46 in their study, in which they discovered the sagittal condylar inclination to be seven degrees more on average than its true anatomic contour in dry skulls. Second, when the occlusal rims are kept in a protruded mandibular position, they exert significant pressure on the mucosa of the denture basal seat, depressing the resilient oral mucosa and bringing the inter-ridge distance closer, resulting in a narrower triangular wedge shaped space between the posterior part of the occlusal rims, similar to the Christensen's space found in natural dentition and documented by protrusive interocclusal records, resulting in a lower value for HCG when positioned in semi-adjustable articulators.20,21 While the results obtained by lateral cephalogram were comparable to that of POR. However, the reference line used in all the included studies is the same, there were variations in the results of the included patients studies which may be because of variation in patients head positioning leading to parallax errors, the models of the panoramic machine, magnification differences, image distortions, overlapping of the mandibular notch, coronoid process, zygomatic arch around TMJ in an OPG and LC as well as the quantitative measurements can be affected by the different operator’s perceptions.7,14,21,23,30,34
The glenoid fossa and the AE can be easily identified since CBCT gives a three-dimensional information for both sides without superimpositions. For both dentate and edentulous individuals, the mean sagittal condylar values obtained from CBCT are slightly greater than those obtained from POR on both sides. Similar results were obtained by the individual studies included in the review, where in the study by Vadodaria43 condylar guidance obtained by CBCT were about 10° more than clinical methods were testified by Jerath et al,25 Kwon et al31 and Naqash et al33 where HCG angle values obtained from CBCT measurements being 5°–6° higher than those from protrusive occlusal records. The most significant advantage of CBCT is that it produces unique pictures that demonstrate characteristics in 3D that intraoral, panoramic, and cephalometric images do not. Cursor-driven measurement methods offer the physician an interactive real-time dimensional evaluation capability. Measurements taken on a computer screen are free of distortion and magnification. Furthermore, CBCT has other advantages such as superior image quality, employing a narrower field of view for a shorter check time, compatibility with various radiographic arrangements for image output, and ease of setup of minimum units in a general clinical context. These CBCT preferences may be utilised to determine the condylar position during dynamic registration in edentulous and dentulous patients and precisely locate the condyle.8,43,53 The main drawback of utilising CBCT is the expensive cost of the equipment.54 For, CT scan and TMJ tomogram radiographic technique only one study in each group was included, hence it is difficult to draw conclusions for these techniques.
Nonetheless, there are several limits to this evaluation. The clinical variability among the selected studies could not be completely avoided. The studies' sample sizes were limited, resulting in a lack of statistical power. None of the investigations correlated HCG angle measurements to actual MRI images, which are the gold standard in diagnosing TMJ problems.9 The eligible studies provided less evidence for inter and intra examiner reliability for radiographic scans and POR. Also, separate analysis was not performed for different methods of recording POR (protrusive wax records, jig’s method and gothic arc tracing), number of missing teeth for partially edentulous patients as well as comparison between different radiographic methods and right and left HCG angles was also not performed. However, to rule out potential causes of heterogeneity, subgroup and sensitivity analyses were done separately for dentate and edentulous individuals for the right and left HCG angle. Likewise, it was difficult to rule out the clinical heterogeneity occurring because of type of radiographic machine, tube voltage, selection of landmarks, head positioning and software capabilities. Only, seven studies were rated as good quality studies, exhibiting a low risk of bias suggesting that in future, high-quality of in-vivo studies assessing the reliability and accuracy of radiographic scans and POR with consistent outcome parameter should be conducted.
Conclusions
The present systematic review and meta-analysis concluded that for the dentate and edentulous patients, the right and left HCG angle values determined by radiographic method showed statistically significant difference as compared to the protrusive occlusal records. Yet, in clinical general practice, the approach most used to assess horizontal condylar inclination is by recording protrusive interocclusal records; however, if not managed properly, this method may result in restoration with distinctive errors. The numerous radiography approaches available through CBCT, OPG, and LC provide unique opportunities to minimise mistakes that may occur as a result of material mishandling while eliminating time-consuming procedures. Therefore, a clinically applicable HCG angle to program semi-adjustable dental articulators can be obtained by adjusting the value measured using CBCT images and pantographic tracings.
Data availability
Underlying data
All data underlying the results are available as part of the article and no additional source data are required.
Reporting guidelines
Open Science Framework: PRISMA checklist for ‘Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis’ https://doi.org/10.17605/OSF.IO/WAQNJ.55
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
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Luke AM, Kuriadom ST, George JM and Wahjuningrum DA. Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis [version 1; peer review: 1 approved]. F1000Research 2022, 11:105 (https://doi.org/10.12688/f1000research.75347.1)
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How to cite this report:
Vinay V. Reviewer Report For: Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis [version 1; peer review: 1 approved]. F1000Research 2022, 11:105 (https://doi.org/10.5256/f1000research.79207.r121335)
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https://f1000research.com/articles/11-105/v1#referee-response-121335
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 08 Mar 2022
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The systematic review is conducted properly. The best features of this systematic review are the process of search strategy, data extraction, and quantitative synthesis of the results.
The language of the manuscript is up to the mark.
... Continue reading
The language of the manuscript is up to the mark.
... Continue reading
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HOW TO CITE THIS REPORT
Vinay V. Reviewer Report For: Accuracy of radiographic and protrusive occlusal record methods in determining condylar guidance angles: a systematic review and meta-analysis [version 1; peer review: 1 approved]. F1000Research 2022, 11:105 (https://doi.org/10.5256/f1000research.79207.r121335)
The direct URL for this report is:
https://f1000research.com/articles/11-105/v1#referee-response-121335
https://f1000research.com/articles/11-105/v1#referee-response-121335
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Author Response 16 Mar 2022Dian Agustin Wahjuningrum, Department of Conservative Dentistry, Faculty of Dental Medicine, Universitas Airlingga, Surabaya City, East Java, 60132, Indonesia16 Mar 2022Author ResponseThank you so much, respected reviewer, for the positive comments to our attempt to perform a systematic review and meta analysis.
We will surely look for more systematic reviews ... Continue reading
COMMENTS ON THIS REPORT
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Author Response 16 Mar 2022Dian Agustin Wahjuningrum, Department of Conservative Dentistry, Faculty of Dental Medicine, Universitas Airlingga, Surabaya City, East Java, 60132, Indonesia16 Mar 2022Author ResponseThank you so much, respected reviewer, for the positive comments to our attempt to perform a systematic review and meta analysis.
We will surely look for more systematic reviews ... Continue reading
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