Journal of

Clinical Medicine

Article
Sagittal Condylar Inclination and Transversal Condylar
Inclination in Different Skeletal Classes
Anahit Lewandowska, Katarzyna Mańka-Malara * and Jolanta Kostrzewa-Janicka

Department of Prosthodontics, Medical University of Warsaw, 02-097 Warsaw, Poland;

anahit.lewandowska@wum.edu.pl (A.L.); jolanta.kostrzewa-janicka@wum.edu.pl (J.K.-J.)
* Correspondence: kmalara@wum.edu.pl

Abstract: Background: During prosthodontic treatment, the averaged values of the transversal
condylar inclination (TCI) and the sagittal condylar inclination (SCI) are used for articulator settings.
This study evaluated different parameters of measurable mandibular movements according to skeletal
classes. Methods: Seventy-five patients (mean age 30.8 ± 5.49) had a condylography using the Cadiax
Compact device (Gamma Dental, Klosterneuburg, Austria) and cephalometric analysis performed.
Statistical analysis was performed using R statistical software. Results: There was no statistical
evidence to state that the value of SCI angle is different in I compared to II Skeletal Class. There were
no statistically significant differences when comparing the I vs. III and II vs. III Skeletal Class. The
lowest mean SCI angle values were found in subjects with Skeletal Class III. There were statistically
significant differences in left-sided TCI between Class I and II. There was a statistically significant
linear relationship between ANB angle value and SCI value. Conclusions: Due to the wide individual
variation in SCI and TCI values, it is advisable to use individual measurable parameters of mandibular
movements during prosthetic reconstructions. The statistically significant relationship between SCI
and ANB angle can be used to individualize the articulating parameters, especially in significant
Citation: Lewandowska, A.;
skeletal disproportions.
Mańka-Malara, K.;
Kostrzewa-Janicka, J. Sagittal
Keywords: occlusion; Cadiax Compact; axiography; cephalometry; temporomandibular joint;
Condylar Inclination and Transversal
temporomandibular disfunction; malocclusion; articulator; prosthodontics; orthodontics
Condylar Inclination in Different
Skeletal Classes. J. Clin. Med. 2022, 11,
2664. https://doi.org/10.3390/
jcm11092664
1. Introduction
Academic Editors: Bruno Chrcanovic
and Manuel O. Lagravère
Increasing expectations of modern life, stressful environments, and global turmoil
lower our ability to adapt. Excessive mental loading has an impact on the stomatognathic
Received: 29 March 2022 system and can be a trigger for temporomandibular dysfunctions [1–5]. Additional local
Accepted: 6 May 2022 factors such as unbalanced occlusion favor the occurrence of such illness. Psychosocial
Published: 9 May 2022 stress is often accompanied by anxiety, hypervigilance, and somatosensory amplification
Publisher’s Note: MDPI stays neutral contributing to pain [1]. Decreased compensatory abilities may also be caused by systemic
with regard to jurisdictional claims in diseases such as endocrine, skeletal, muscular, psychosomatic, and psychiatric disorders.
published maps and institutional affil- When the indicated diseases are present, we may expect difficulties in achieving the clinical
iations. goals [6–8]. Moreover, all patients have a differing thin sensitivity to occlusal changes,
which is influenced by many factors [9,10].
Prosthetic rehabilitation should not only replace missing tissues but also maintain the
health of a patient [11–13]. Every dental appliance should be harmonized with the mastica-
Copyright: © 2022 by the authors. tory system, movement patterns, and even head posture. The use of appliances that track
Licensee MDPI, Basel, Switzerland. the movement of the mandible enables the calculation of the sagittal condylar inclination
This article is an open access article
(SCI) and the transversal condylar inclination (TCI) [13–16]. Such devices are, for instance,
distributed under the terms and
the electronic Cadiax Compact (Gamma Dental, Klosterneuburg, Austria), ultrasonic AR-
conditions of the Creative Commons
CUSdigma (Kavo, Biberach, Germany) or optoelectric Condylocomp (Dentron, Höchberg,
Attribution (CC BY) license (https://
Germany). The use of the SCI, the TCI, the curve of Spee, the Wilson curve, and the
creativecommons.org/licenses/by/
inclination of the occlusal plane is necessary to individualize the prosthodontic treatment.
4.0/).

J. Clin. Med. 2022, 11, 2664. https://doi.org/10.3390/jcm11092664 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2022, 11, 2664 2 of 13

Current prosthodontics focus on novel materials mimicking nature. Digital treatment

planning and 3D printing have brought us to a new era. In this era, however, we cannot
ignore function and occlusion. Major skeletal and dentoalveolar discrepancies are corrected
nowadays by orthognathic surgery and orthodontics. Many patients, however, have some
skeletal disproportions camouflaged—by nature or an orthodontist—or only want to solve
their dental problems by prosthodontic rehabilitation. Such treatment must always be con-
ducted with respect to the patient’s anatomy. Therefore, the purpose of our research was to
evaluate the differences between standard SCI and TCI parameters used in prosthodontics
and those calculated according to skeletal classes.

2. Materials and Methods

The research included 75 patients (52 females and 23 males) aged from 22 to 44 years
(mean 30.8 ± 5.49). They were recruited from among patients at the Medical University of
Warsaw University Dental Center. All patients who met the inclusion criteria for the study
and approved for participation were included in the research. The study protocol was
approved by the Bioethics Committee at the Medical University of Warsaw (KB/189/2017).
The investigation was carried out following the rules of the Declaration of Helsinki of
1975, revised in 2013. All participants have given written, informed consent to participate.
They were also provided with a copy of the information along with their doctor’s contact
information. The medical interview and dental examination included the evaluation of the
stomatognathic system. The inclusion criteria included the presence of complete dentition
and age between 18 and 45 years. The exclusion criteria were previous craniofacial surgery
or orthodontic treatment, temporomandibular disorders, systemic diseases, and contraindi-
cations to radiography. A preliminary examination involved evaluating the mandibular
range of motion and the soreness of the muscles of the head and neck region—the tempo-
ralis, masseter, lateral and medial pterygoid area, and sternocleidomastoid muscles.
Condylography using the Cadiax Compact (Gamma Dental, Klosterneuburg, Austria)
was used to obtain data for the articulator settings: the angle of the articular pathway
in the sagittal and transversal planes (SCI, TCI) (Figures 1 and 2). Patients practiced
instructed mandibular movements before actual condylographic examination. The patient
did maximal opening, protrusive, and lateral movements at a specified timing. Each
practiced movement ended and began from the starting position (reference position)—the
mandible located in the maximally retrusive position in which lateral movements were
possible, without dental contacts and applied force. All movements of patients during
the examination were carefully observed by the operator and registered in the software
(Figure 3). The assessment was performed in the Gamma Dental software. SCI and TCI
results obtained on 5 mm of motion were used for subsequent analysis. The cephalometric
analysis was conducted for each participant of the study according to the Steiner analysis
using the Gamma Dental software (Gamma Dental, Klosterneuburg, Austria). The sagittal
jaw relationship was classified using the ANB angle. All condylographic registrations were
done by one operator in the Department of Prosthodontics at the Medical University of
Warsaw University Dental Center.
Statistical analysis was performed using the R statistical software [17]. Mean SCI and
TCI values in the skeletal Class distributions were compared using the Student’s T-test
(p-values and power analyses are reported in the next section). In each skeletal class, the
SCI and TCI distributions showed the characteristics of a normal distribution according
to the Shapiro-Wilk test. The relationship between the ANB angle, SCI, and TCI values
were analyzed for the right and left temporomandibular joint (TMJ). Patients were divided
into three groups: Skeletal Class I (23 patients), Skeletal Class II (29 patients), and Skeletal
Class III (23 patients), according to the cephalometric analysis.
J.J.Clin.
Clin.Med. 2022,11,
Med.2022, 11,2664
x FOR PEER REVIEW 33 of 13
13
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 3 of 13

Figure1.
Figure
Figure 1.Condylography
1. Condylographyusing
Condylography usingthe
using theCadiax
the CadiaxCompact—front
Cadiax Compact—frontimage.
Compact—front image.
image.

Figure 2.
Figure 2. Condylography
Condylography using
using the
the Cadiax
Cadiax Compact—lateral
Compact—lateral image.
image.
Figure 2. Condylography using the Cadiax Compact—lateral image.
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 4 of 13
J. Clin. Med. 2022, 11, 2664 4 of 13

Figure
Figure3.3.Registration
RegistrationininCadiax
CadiaxCompact
Compactduring
duringthe
theprotrusion
protrusionmovement.
movement.

ToTodetermine
determinedifferences
differencesbetween
betweenmeasures
measureswithin
withinthe
theskeletal
skeletalclasses,
classes,we weconducted
conducted
Student’s t-tests. The null hypothesis in Student’s t-test states that means
Student’s t-tests. The null hypothesis in Student’s t-test states that means within compared within compared
groups are equal, whereas we chose to pick a two-sided alternative
groups are equal, whereas we chose to pick a two-sided alternative hypothesis which hypothesis which
states that means within compared groups are not equal. The assumed
states that means within compared groups are not equal. The assumed significance level significance level
(TypeI Ierror
(Type errorprobability)
probability)was wassetsettoto0.05,
0.05,where
wherethethestatistical
statisticalpower
power(1(1minus
minusTypeTypeIIIIerror
error
probability) for sample size calculations was set to 0.80. Type I error is
probability) for sample size calculations was set to 0.80. Type I error is the situation wherethe situation where
thenull
the nullhypothesis
hypothesis is is true,
true, but
but it’s
it’s rejected
rejected duedueto tothe
theanalysis,
analysis,whereas
whereasType Type II error is the
II error is
the situation where the null hypothesis is not rejected while the alternative hypothesistrue.
situation where the null hypothesis is not rejected while the alternative hypothesis is is
We calculated
true. We calculatedp-values (often(often
p-values treatedtreated
as a probability of a nullofhypothesis
as a probability is true) which
a null hypothesis is a
is true)
boundary
which is a for specifying
boundary for aspecifying
statisticallya significant
statisticallyfinding whenfinding
significant compared whento the significance
compared to
level. Independently of p-values calculations, we also reported the
the significance level. Independently of p-values calculations, we also reported the statis- statistical power [X]
of each
tical power test.
[X]The statistical
of each power
test. The of a hypothesis
statistical power of atest is the probability
hypothesis test is the of detecting of
probability an
effect if there is a true effect present to detect (often explained as the probability that the
detecting an effect if there is a true effect present to detect (often explained as the proba-
test correctly rejects the null hypothesis. The sizes of each group (samples) have an impact
bility that the test correctly rejects the null hypothesis. The sizes of each group (samples)
on the outcome of the results of tests as their test statistics are based on sample means,
have an impact on the outcome of the results of tests as their test statistics are based on
sample standard deviations, and sample standard errors, which are influenced by the group
sample means, sample standard deviations, and sample standard errors, which are influ-
(samples) sizes. Sample size calculations were reported as well to determine the minimum
enced by the group (samples) sizes. Sample size calculations were reported as well to de-
group size for the test to detect statistically significant findings for the observed sample
termine the minimum group size for the test to detect statistically significant findings for
means, sample standard deviations, sample standard errors, assumed Significance level
the observed sample means, sample standard deviations, sample standard errors, as-
(0.05), and assumed statistical power (0.80). Below we report the p-value, statistical power
sumed Significance level (0.05), and assumed statistical power (0.80). Below we report the
(power), and sample size needed to detect the effect (SSN) in parentheses [18].
p-value, statistical power (power), and sample size needed to detect the effect (SSN) in
parentheses
3. Results [18].
The mean SCI value of the left TMJ for all studied groups was 49.2◦ (SD = 8.5◦ ,
3. Results ◦
SE = 0.98 ), (Table 1), while the mean SCI value of the right joint for all studied groups
wasThe49.7mean
◦ (SD= SCI9.3value
◦ , SE of the ◦left
= 1.07 TMJ for
) (Table 2). all
The studied
result groups was 49.2° t-test
of the Student’s (SD =for 8.5°,
theSESCI
=
0.98°), (Table 1), while the mean SCI value of the right joint for
values of the left side in Skeletal Classes I and II did not provide sufficient grounds to all studied groups was
49.7° (SD= that
conclude 9.3°,the
SEdistributions
= 1.07°) (Table 2). Thethese
between resultclasses
of thewere
Student’s t-test for
statistically the SCI values
significantly of
different
the left side
(p-value in Skeletal
= 0.69, powerClasses
= 0.06, SSNI and= II1475).
did not provideClass
In Skeletal sufficient
I, thegrounds
mean lefttoside conclude
SCI was 51◦
that
the
(SD=distributions
7.90, SE = 1.65 ◦
between), and these classes Class
in Skeletal were statistically
II, the meansignificantly
left side SCI different ◦ (SD= 7.6=◦ ,
was 51.8 (p-value
0.69,
SE =power ◦
1.41 ).=According
0.06, SSN to = 1475). In Skeletal
the results Class I, the
of the Student’s meanthese
T-tests, left side
values SCIwere wasstatistically
51° (SD=
7.90, SE = 1.65°),
significantly and in from
different SkeletaltheClass
SCI of II, the
the left
mean TMJleftfor
side SCI was
Skeletal 51.8°
Class III,(SD=
for 7.6°,
which SEthe
=
1.41°). According ◦ to the ◦
results of the ◦
Student’s T-tests, these values
mean was 43.6 (SD= 8.1 , SE = 1.69 ), (Table 1; Figure 4), (p-values: I vs. III = 0.005, II vs.were statistically sig-
nificantly different
III = 0.000; powers:from I vs.theIII =SCI of II
0.86, thevs.left
IIITMJ forSSNs:
= 0.95; Skeletal Class
I vs. III =III,
19,for which
II vs. III =the mean
15)).
was 43.6° (SD= 8.1°, SE = 1.69°), (Table 1; Figure 4), (p-values: I vs. III = 0.005, II vs. III =
0.000; powers: I vs. III = 0.86, II vs. III = 0.95; SSNs: I vs. III = 19, II vs. III = 15)).
J. Clin. Med. 2022, 11, 2664 5 of 13

Table 1. Sagittal condylar inclination (SCI) of the left temporomandibular joint (TMJ).

Class N Min Q1 Median Average Q3 Max SD SE

All 75 32 43.0 50.0 49.2 55.5 70 8.5 0.98
I 23 32 45.8 51.5 51.0 55.8 70 7.9 1.65
II 29 39 47.0 52.0 51.8 56.0 70 7.6 1.41
III 23 32 37.2 42.5 43.6 49.5 61 8.1 1.69
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 5 of 13
N, number of patients in the group; Min, minimal recorded value of the measure; Q1, first quartile of the recorded
value of the measure; Median, median recorded value of the measure; Average, average recorded value of the
measure; Q3, third quartile of the recorded value of the measure; Max, maximum recorded value of the measure;
SD, standard deviation of the recorded value of the measure; SE, standard error of the average recorded value of
the measure.
Table 1. Sagittal condylar inclination (SCI) of the left temporomandibular joint (TMJ).

Table
Class2. Sagittal
N condylar
Min inclination
Q1 (SCI) of the right
Median TMJ.
Average Q3 Max SD SE
All 75 32 43.0 50.0 49.2 55.5 70 8.5 0.98
Class N Min Q1 Median Average Q3 Max SD SE
I 23 32 45.8 51.5 51.0 55.8 70 7.9 1.65
All 75 24 44.0 50 49.7 55.0 70 9.3 1.07
II 29 39 47.0 52.0 51.8 56.0 70 7.6 1.41
I 23 40 49.2 52 52.2 55.8 70 6.7 1.40
III
II 2329 32 28 37.246.8 42.552 43.6
51.8 49.5
55.2 7061 8.1
9.2 1.69
1.71
N, number
III of 23
patients in
24 the group;
38.0 Min, minimal
41 recorded
44.2 value50.0
of the measure;
64 Q1,
9.7first quartile
2.02
of the recorded value of the measure; Median, median recorded value of the measure; Average,
N, number of patients in the group; Min, minimal recorded value of the measure; Q1, first quartile of the recorded
average
value of recorded value
the measure; of themedian
Median, measure; Q3, third
recorded valuequartile of the recorded
of the measure; Average, value ofrecorded
average the measure;
valueMax,
of the
measure; Q3,
maximum third quartile
recorded valueofofthe recorded
the value
measure; SD,of standard
the measure; Max, maximum
deviation recorded value
of the recorded value of
ofthe
themeasure;
meas-
SD, standard deviation of the recorded value of the measure; SE, standard error of the average recorded value of
ure; SE, standard error of the average recorded value of the measure.
the measure.

5 9 49 21 16 8 18 57 15 76
6 1
I 33 50 68 55
66 42 26 59 63
72

38 13 58 23 44 62 74 75 46 61 32 31 60 39
3
II 25 17 14 52 37
51 43 22 45 24 27 48 40 35

41 7 36 53 34 11 71 20 73 30 4
III 67 64 28 10
69 54 2 12 56

40 50 60 70

Thedistribution
Figure4.4.The
Figure distributionofofthe
theleft
leftsagittal
sagittalcondylar
condylarinclination
inclination(SCI)
(SCI)coefficient
coefficientvalue.
value.Numbers
Numbers
representpatients’
represent patients’ IDs.
IDs.

Table There wascondylar

2. Sagittal no evidence to prove
inclination significant
(SCI) of statistical differences between the SCI
the right TMJ.
values for the right side when comparing Skeletal Classes I and II, according to the Student’s
Class(p-value
T-test N =Min Q1 = 0.05,
0.85, power Median
SSN ≥ 1000).AverageIn Skeletal Q3Class Max SD SCI of
I, the mean SEthe
joint was 52.2 (SD = 6.7 , SE = 1.40 ), and in Class II it was 51.80 (SD = 9.2 , SE = 1.71◦ )
All 75 ◦ 24 ◦
44.0 ◦
50 49.7 55.0 70 ◦
9.3 1.07
(TableI 2). According
23 40 to the
49.2results 52of the Student’s52.2 t-test, these
55.8 values 70 were 6.7statistically
1.40
significantly
II 29 different
28 from 46.8the SCI of52 the right joint
51.8 in Skeletal55.2 Class70 III, which
9.2 was1.7144.2◦
(SD= ◦ ◦
III 9.70 ,23SE = 2.02
24 ) (Figure
38.0 5), (p-values:
41 I vs.44.2
III = 0.003,50.0
II vs. III 64
= 0.008,9.7
powers: I vs.
2.02
III = 0.88, II vs. III = 0.81, SSNs: I vs. III = 18, II vs. III = 25). It is worth noting
N, number of patients in the group; Min, minimal recorded value of the measure; Q1, first quartile that the SCI
trends in the left and right joints according to skeletal classes were similar.
of the recorded value of the measure; Median, median recorded value of the measure; Average, For Skeletal
Class II,recorded
average the mean SCIofvalues
value of theQ3,
the measure; right and
third left sides
quartile of thewere consistent.
recorded value of the measure; Max,
maximum recorded value of the measure; SD, standard deviation of the recorded value of the meas-
ure; SE, standard error of the average recorded value of the measure.

There was no evidence to prove significant statistical differences between the SCI
values for the right side when comparing Skeletal Classes I and II, according to the Stu-
dent’s T-test (p-value = 0.85, power = 0.05, SSN ≥ 1000). In Skeletal Class I, the mean SCI
of the joint was 52.2° (SD = 6.7°, SE = 1.40°), and in Class II it was 51.80 (SD = 9.2°, SE =
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 6 of 13

J. Clin. Med. 2022, 11, 2664 SCI trends in the left and right joints according to skeletal classes were similar. For Skeletal
6 of 13
Class II, the mean SCI values of the right and left sides were consistent.

5 57 76 1 63 16 8 66 42 15
9
I 50
21
55 68 6 18 26 72 49 59
33

48
13 61
38 43 51 52 44 3 22 14 75 60 62 24
II 17
39
37 23
25 58 74 31 46 35 45 27
40

11 67 53 64 10 30 28 7 4
III 69 41
34
56 73
54 12 36 71 20 2 65

30 40 50 60 70

Figure 5.
Figure Thedistribution
5. The distribution of
of the
the right
right sagittal
sagittal condylar
condylar inclination
inclination ((SCI)
SCI) coefficient
coefficient value.
value. Numbers
Num-
represent
bers patients’
represent IDs. IDs.
patients’

The mean
mean TCI
TCI of
of the
the left
left TMJ
TMJ for
for all
all skeletal classes was
was 4.1 ◦ (SD = 4.6◦ , SE = 0.53◦ )
The skeletal classes 4.1° (SD = 4.6°, SE = 0.53°)◦
(Table 3), while the mean TCI of the right TMJ for all study groups
(Table 3), ◦while the mean TCI of the right TMJ for all study groups was 4.30 was 4.30 (SD
(SD == 5.20°,
5.20 ,
SE ==0.60°)
SE 0.60 )(Table
(Table4).
4).According
Accordingto tothe
theresults
results of
of the
the Student’s T-tests, there
Student’s T-tests, there was
was no
no signif-
signifi-
cant statistical evidence to conclude that TCI values on the left side differed
icant statistical evidence to conclude that TCI values on the left side differed between between Class
II and III and Class I and III. The Student’s T-test determined that there were statistically
Class II and III and Class I and III. The Student’s T-test determined that there were statis-
significant differences in left-sided TCI between Class I and II. In Skeletal Class I the left side
tically significant differences in left-sided TCI between Class I and II. In Skeletal Class I
mean TCI was 6.0◦ (SD = 5.0◦ , SE = 1.04◦ ), in Skeletal Class II 3.2◦ (SD = 3.6◦ , SE = 0.67◦ ),
the left side mean TCI was 6.0° (SD◦ = 5.0°, SE◦= 1.04°), in◦Skeletal Class II 3.2° (SD = 3.6°,
while in Class III the mean was 3.6 (SD = 5.1 , SE = 1.06 ) (Table 3; Figure 6), (p-values: I
SE = 0.67°), while in Class III the mean was 3.6° (SD = 5.1°, SE = 1.06°) (Table 3; Figure 6),
vs. III = 0.756, II vs. III = 0.107, I vs. II = 0.027, powers: I vs. III = 0.35, II vs. III = 0.06, I vs.
(p-values: I vs. III = 0.756, II vs. III = 0.107, I vs. II = 0.027, powers: I vs. III = 0.35, II vs. III =
II = 0.62, SSNs: I vs. III = 70, II vs. III ≥ 1000, I vs. II = 39). It could not be concluded that
0.06, I vs. II = 0.62, SSNs: I vs. III = 70, II vs. III ≥ 1000, I vs. II = 39). It could not be concluded
the TCI values of the right side in each skeletal class were statistically significantly different.
that the TCI values of the right side in each◦ skeletal ◦class were statistically significantly◦
In Skeletal Class I the right TMJ TCI was 5.2 (SD= 6.0 , SE = 1.250), in Skeletal Class II 4.1
different.◦ In Skeletal◦ Class I the right TMJ TCI was 5.2° (SD= 6.0°, SE = 1.250), in Skeletal
(SD= 5.1 , SE = 0.95 ), and in Skeletal Class III 3.6◦ (SD= 4.5◦ , SE = 0.94◦ ) (Table 4; Figure 7),
Class II 4.1° (SD= 5.1°, SE = 0.95°), and in Skeletal Class III 3.6° (SD= 4.5°, SE = 0.94°) (Table
(p-values: I vs. III = 0.323, II vs. III = 0.692, I vs. II = 0.511, powers: I vs. III = 0.17, II vs.
4; Figure 7), (p-values: I vs. III = 0.323, II vs. III = 0.692, I vs. II = 0.511, powers: I vs. III =
III = 0.06, I vs. II = 0.10, SSNs: I vs. III = 173, II vs. III ≥ 1000, I vs. II = 40).
0.17, II vs. III = 0.06, I vs. II = 0.10, SSNs: I vs. III = 173, II vs. III ≥ 1000, I vs. II = 40).
Table 3. Transversal condylar inclination (TCI) of the left temporomandibular joint (TMJ).
Table 3. Transversal condylar inclination (TCI) of the left temporomandibular joint (TMJ).
Class N Min Q1 Median Average Q3 Max SD SE
Class N Min Q1 Median Average Q3 Max SD SE
All 75 0 0.0 3.0 4.1 6.0 18 4.6 0.53
All I 7523 0 0 0.01.5 3.05.5 4.1
6.0 6.0
10.5 18
17 4.6
5.0 0.53
1.04
III 2329 0 0 1.50.0 5.53.0 6.0
3.2 10.5
5.0 17
16 5.0
3.6 1.04
0.67
II
III 2923 0 0 0.00.0 3.02.0 3.2
3.6 5.0
4.0 16
18 3.6
5.1 0.67
1.06
N, number
III of patients
23 in
0 the group;
0.0 Min, minimal
2.0 recorded value
3.6 of the measure;
4.0 Q1, first
18 quartile
5.1 of the recorded
1.06
value of the measure; Median, median recorded value of the measure; Average, average recorded value of the
N, number of patients in the group; Min, minimal recorded value of the measure; Q1, first quartile
measure; Q3, third quartile of the recorded value of the measure; Max, maximum recorded value of the measure;
of
SD,the recorded
standard valueofof
deviation thethe measure;
recorded valueMedian, median
of the measure; SE,recorded value
standard error of of
thethe measure;
average Average,
recorded value of
average recorded value of the measure; Q3, third quartile of the recorded value of the measure; Max,
the measure.
maximum recorded value of the measure; SD, standard deviation of the recorded value of the meas-
ure; SE, standard error of the average recorded value of the measure.
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J. Clin. Med. 2022, 11, 2664 7 of 13

70 55 50 1 9 6
57 5 76 21 8
I 72 59 26 16 63 18 68 15
66 49 33
70 55 50 1 9 6
57 5 76 21 8
I 72 59 26 16 63 18 68 15
66 49 33

14
3 35 27 51 39
II 32 31 61 25 74
44 13 14
3 35 27 51 39
II 32 31 61 25 74
44 13

28 34 56 11
7 53 65 64
III 2 19 30 36 71
47
28 34 56 11
7 53 65 64
III 2 19 30 36 71
47

0 5 10 15

0 Figure 6. The5 distribution of the left transversal

10 condylar inclination15
(TCI) coefficient value. Num-
bers represent patients’ IDs.
Figure 6.
Figure The distribution
6. The distribution of
of the
the left
left transversal
transversalcondylar
condylarinclination
inclination(TCI)
(TCI)coefficient value.
coefficient Numbers
value. Num-
represent
bers patients’
represent IDs. IDs.
patients’
Table 4. Transversal condylar inclination (TCI) of the right TMJ.
Table
Table 4. Transversal
4. Transversal
Class N condylar
Min inclination
condylarQ1 (TCI)
(TCI) of
Median
inclination of the right
right TMJ.
Average
the TMJ. Q3 Max SD SE
All
Class 75
N 0
Min 0
Q1 2
Median 4.3
Average Q37 22
Max 5.2
SD 0.60
SE
Class N Min Q1 Median Average Q3 Max SD SE
I 23 0 0 3 5.2 7 22 6.0 1.25
All
All 75 00 00 22 4.3
4.3 77 22
22 5.2
5.2 0.60
0.60
III
I
29
23
23
00
0
00
0
23
3
4.1
5.2
5.2 77
7
15
22
22
5.1
6.0
6.0
0.95
1.25
1.25
III
II 23
29 00 00 22 3.6
4.1 75 16
15 4.5
5.1 0.94
0.95
II 29 0 0 2 4.1 7 15 5.1 0.95
III
N, number of 23 0 the group;
patients in 0 Min, minimal
2 3.6 value of
recorded 5 the measure;
16 4.5first quartile
Q1, 0.94
III 23 0 0 2 3.6 5 16 4.5 0.94
of the recorded value of the measure; Median, median recorded value of the measure; Average,
N, number of patients in the group; Min, minimal recorded value of the measure; Q1, first quartile of the recorded
N, number
value of the
average of patients
measure;
recorded value in
ofthe
Median, group;
themedian Min,Q3,minimal
recorded
measure; ofrecorded
valuequartile
third value
the measure;
of the of the value
Average,
recorded measure;
average Q1, first
ofrecorded
the quartile
value
measure; of the
Max,
of the recorded
measure;
maximum Q3, thirdvalue
recorded ofofthe
quartile
value the
of measure;
recorded
the measure; Median,
value
SD, themedian
of standard
measure; recorded ofvalue
Max, maximum
deviation of the measure;
recorded
the recorded value Average,
valueofofthe
themeasure;
meas-
SD, standard
average deviation
recorded of the
value recorded
ofthe
the valueQ3,
measure; of the measure;
third SE,of
quartile standard
the error ofvalue
recorded the average
of therecorded
measure; value
Max,of
ure; SE, standard
the measure. error of average recorded value of the measure.
maximum recorded value of the measure; SD, standard deviation of the recorded value of the meas-
ure; SE, standard error of the average recorded value of the measure.

21 66 76 1 72
I 55 57 68 6 15 33 8 63
5 26
21 66 76 1 72
I 55 57 68 6 15 33 8 63
5 26

45 13
40 22 31 58 32 51 60
II 48 46 27 43 14 23 24
61 35 62
45 13
40 22 31 58 32 51 60
II 48 46 27 43 14 23 24
61 35 62

56 73 30 19
III 34 53 4 67 20 64
56 73 30 19
III 34 53 4 67 20 64

0 5 10 15 20

0 Figure57.
Figure Thedistribution
7. The distributionof 10
ofthe
theright
right TCI coefficient15
TCI coefficient value. Numbers
value. 20 patients’
Numbers represent
represent patients’ IDs.
IDs.

FigureIn7.the
Thesecond part of
distribution ofthe
the analysis,
right TCI the correlation
coefficient value.between
Numbersthe right and
represent the leftIDs.
patients’ side SCI
In the second part of the analysis, the correlation between the right and the left side
andand
SCI ANBANB angle was was
angle evaluated. For this
evaluated. For purpose, in both
this purpose, in cases, a linear
both cases, regression
a linear model
regression
was In the (Table
fitted second5).
part
It of
wastheverified
analysis, thethe
that correlation between
assumptions the models
of both right and the met
were left side
and
SCI
thatand ANB angle
the models’ wasofevaluated.
quality For this purpose,
fits were appropriate in both of
(the residuals cases, a linearhad
the models regression
normal
J. Clin. Med. 2022, 11, 2664 8 of 13

distributions, and the variances of the residuals were homogeneous). The models showed
mean values of left SCI (47.5) and right SCI (48.5) and statistically significant coefficients for
ANB: left SCI (0.77) and right SCI (0.72). This means that (according to linear models), on
average, the left SCI was 47.5, and for each ANB, it should be increased by ANB × 0.77, and
on average, the right SCI was 48.5, and for each ANB, it should be increased by ANB × 0.72.
In the model for the left SCI, the result of the general F-test for the linear model stated
that this model was statistically significantly more effective in predicting left SCI based on
ANB than when predicting left SCI without any knowledge (null model) (p-value = 0.012).
The R2 statistic was 0.098, meaning that ANB explains 9.8% of the variability associated
with the left SCI distribution. For the model predicting right SCI, the general F-test for the
linear model shows that the model is statistically significantly more effective in predicting
right SCI based on ANB than when predicting right SCI without any knowledge (null
model) (p-value = 0.039). The R2 statistic was 0.069, meaning that ANB explains 6.9% of the
variability associated with the right SCI distribution.

Table 5. The linear regression models.

The Coefficient for the ANB Angle The Average from the Model The p-Value of Test F R2
SCI Left 0.77 47.5 0.012 0.098
SCI Right 0.72 48.5 0.039 0.069

4. Discussion
The use of individual TMJ movement parameters is important to provide properly
fitted prosthetic restorations. The setting of SCI and TCI values in articulators is an
important factor in the individualization of occlusal reconstruction. In the obtained results,
the mean SCI value calculated for the left TMJ was 49.2◦ . The same value for the right joint
was 49.7◦ . The average SCI, according to literature, is between 20–33◦ [19]. These findings
are comparable with studies by other authors.
Using the Cadiax Compact, Ruwaida et al. [20] showed a mean SCI for the left joint
that was 41.9◦ (SD = 9.2◦ ) and for the right joint 42.0◦ (SD 8.5◦ ). This study showed no
statistically significant differences in SCI values for the left and right TMJs between Skeletal
Class I and II subjects. In the left joint, the correlation of SCI in Skeletal Class I compared
to Skeletal Class II was 51◦ vs. 51.8◦ . Statistically significant different (p < 0.05) results
were presented by Canning et al. [21], who obtained SCI values for the left joint in Skeletal
Class I of 46.38◦ compared to Skeletal Class II of 48.93◦ . Similar correlations were found in
the evaluation of the right joint SCI in Skeletal Class I vs. Skeletal Class II 44.13◦ vs. 49.00◦ .
Statistical analysis was performed with the Student’s t-test, and SCI values were obtained
with the Cadiax Compact device, like in the presented study. However, the classification
of classes in that research was obtained by evaluating profile photographs of the patients.
Another difference between the study conducted by the authors Canning et al. [21] is that
no statistical significance was found between Class I and III, whereas in the results obtained
in our study, statistically significant differences were found between Skeletal Class I vs. III
(p = 0.005 in the left joint, p = 0.003 in the right joint), and Skeletal Class II vs. III (p = 0.000
in the left joint, p = 0.008 in the right joint). The obtained SCI values in Skeletal Class III are
the lowest among all researched groups in both studies. Zimmer et al. [22] compared SCI
values in skeletal classes similarly to the aforementioned study and obtained significant
statistical differences between Skeletal Classes I and III. This study also shows the highest
SCI values in Skeletal Class II, which is not reported in our study, but is consistent with the
results of Canning et al. [21].
In presented research, no statistically significant differences in TCI values were found
between I vs. III and II vs. III skeletal classes in the left joint. Statistical significance of the
difference in TCI values occurred only in the comparison of I vs. II Skeletal Class in the left
joint. Cimić et al. [23] found no statistically significant relationship between the TCI value
and the Angle Class exhibited in the results of their study. The average TCI value in our
J. Clin. Med. 2022, 11, 2664 9 of 13

study was 4.1◦ in the left joint and 4.3◦ in the right joint. In the study by Cimić et al. [23] the
value was 6.3◦ in the left joint and 7.7◦ in the right joint. The highest TCI values were found
by the authors in subjects with Angle class III, which is not consistent with the results of the
abovementioned study. However, the Angle classification reports only the dentoalveolar
discrepancies, while in current research, the compared patients were classified in sagittal
skeletal classes based on ANB angle. The used parameter may influence the achieved
results as the studies on the validity of the ANB and Wits appraisal to show that there are
many distorting factors. The ANB angle can differ because of variance in the length of the
cranial base or rotation of the jaws [24–27], while the Wits appraisal can be affected by the
inclination of the occlusal plane [28–30].
The highest TCI value was obtained in Skeletal Class I. Mean TCI values in this study
in all skeletal classes are also different from the results of other authors who obtained
higher values of the above parameters [31]. These differences may be related to different
research protocols and methodology. The use of measuring devices to determine TCI gives,
on average, results with lower values of these parameters compared to the measurement
performed with occlusal registrations [32–35]. At the same time, all obtained average TCI
results in the mentioned articles are lower than those routinely used for articulator settings—
amounting to 15◦ [23]. Obtained results show a significant statistical relationship between
SCI and ANB. The ANB angle value explains 9.8% of the variability associated with the
left SCI distribution and 6.9% of the variability associated with the right SCI distribution.
This means that there is a linear relationship between ANB and SCI. At the same time, the
value of the SCI angle is influenced by other modifying factors. The influence of various
factors on SCI has been studied in the literature, but often the results were not statistically
significant. Among others, the impact of age, gender, condylar process shape, missing teeth,
and TMJ disorders (symptoms and signs of TMD) on the influence of the parameters of
measurable mandibular movements were negated [21,33,34]. The SCI and TCI parameters
in various skeletal patterns are clinically comparable. It would not be a major mistake to
use standardized values for all skeletal classes. However, in the current study, we presented
the recommended corrections for SCI according to the ANB angle. The introduction of such
a formula is clinically important. However, the suggested corrections should be verified in
further studies on larger groups.
In the presented research, the SCI and TCI results were obtained on 5 mm of motion.
The reason for choosing that parameter was to have a relationship in which we could
achieve the necessary space for possible prosthodontic reconstruction and to avoid possible
occlusal interferences caused by a malocclusion. There are publications in the literature that
did not consider the value of the displacement path in protrusion motion in the determina-
tion of SCI values [35–40]. Studies taking into account the value of the displacement path in
protrusion motion showed that there are no statistically significant differences in the calcu-
lation of SCI values depending on measurements made on 3 mm or 5 mm of movement in
the protrusion (41.22 ± 9.71 degrees vs. 41.89 ± 8.62 degrees). The authors also recommend
recording the SCI at 5 mm of protrusion because it provides a more accurate interpretation
of the condylar process motion that is not affected by the natural curvature of the condylar
path that occurs at the first 3 mm of motion. There were also no statistically significant
differences between the SCI value calculated at 3 mm and 5 mm when comparing the
Frankfurt and Camper reference planes [16,34–36,41–43]. There were statistically signifi-
cant differences in SCI values at 3 mm and at 5 mm in studies using either the Frankfurt or
Camper compared to the AOP plane. Studies using the Frankfurt plane were conducted by
Theusner et al. [44] using the SAM electronic device (mean SCI 35 ± 7 degrees) and by Han
et al. [42] using the CADIAX electronic device (mean SCI 40.01 ± 8.12) on the Frankfurt
plane show statistically significant differences—approximately 15 degrees smaller values—
compared to studies conducted using the Axis Orbital Plane (AOP) on SAM axiography by
Kucukkeles et al. [37] (mean SCI 53.3) or Boulos et al. [45] (mean SCI 51.4 ± 9.75 degrees).
There are many publications in the current literature on differences resulting from
various skeletal patterns. Patients with skeletal malocclusion have impaired masticatory
J. Clin. Med. 2022, 11, 2664 10 of 13

abilities and performance in comparison with the control group [34,46]. English et al. [46]
also found that individuals with Class III malocclusion had the lowest masticatory per-
formance compared with other malocclusion groups. However, in this research, vertical
relations were not considered. Research conducted by Ugoloni et al. [47], which analyzed
nine Skeletal Class III patients scheduled for orthognathic surgery, showed that the range
of movement in Class III patients was comparable to that found in normal subjects. They
stated that TMJ kinematics in such subjects was modified, both left and right condyles had
a variable degree of hypomobility, and the condyle translational movement was reduced.
Abrahamsson et al. [34] described that open bite is the discrepancy that has an impact on the
masticatory performance index (MPI). They suggest that the increase in occlusal contacts
after orthodontic treatment may contribute to higher efficiency in mastication. Tamimi
et al. [48] stated that occlusal bite force greatly improves after surgical correction of vertical
morphology in high angle mandibular prognathic patients. The bite force is correlated
with parameters such factors as the mandibular length and mandibular angle at the gonion
point, facial length, and the masseter muscle thickness [49–51]. Kostrzewa-Janicka [52]
described a formula, calculated by cephalometric analysis, for a vertical jaw separation in
which the bite force is minimal.
Many authors also concentrate on comparing TMJ anatomy in different skeletal rela-
tionships. Santander et al. [53] show a correlation between skeletal patterns and condylar
morphology in the adult population. They conducted a CBCT study on 111 patients
showing that Skeletal Class II correlates with smaller, shorter, and more inclined condyles
compared to Class III subjects. Facial asymmetry determined by menton point deviation
did not mirror differences in condylar shape or inclination. Similar results were achieved
by Hasebe et al. [54], who described that Class II patients or those with hyperdivergent
skeletal patterns had small condylar sizes, and subjects with Class III or hypodivergent
skeletal patterns had large condylar sizes. Additionally, females had smaller condyles than
males. There are also differences in the condyle-fossa relationships between patients with
different skeletal patterns [55–57]. Despite reported differences, neither the sex nor the
dimension of the condyle influence the SCI. The condyle is positioned more inferiorly in
hypodivergent than hyperdivergent Skeletal Class II patients. According to Katsavrias [58],
the articular eminence height and articular eminence inclination are highly correlated to
ramus inclination.
The major limitation of the presented study is the small sample size for the variables
in the assessment. However, data published by other authors using similar methodology
included comparable or smaller groups. Han et al. [42] conducted research on a group of
10 patients, Torabi et al. [16] included 22 participants, Hernandez et al. [31]—45 patients,
Schierz et al. [33]—65 patients, and Canning et al. [21]—73 patients. Condylographic
examination is time-consuming but provides precise articulating parameters. It would
be beneficial to examine more patients in each group for verification of the achieved
results. Additionally, further studies will enable the provision of a precise correction for
SCI according to the ANB angle.
In summary, prosthetic restorations should provide both missing structures and func-
tions. The use of condylography enables the precise evaluation of condyle movement
and thus reproduces and reconstructs the occlusal relations. Due to the similar values of
SCI and TCI, standard parameters can be used in different skeletal classes. However, due
to the wide individual variation in SCI and TCI values, it is advisable to use individual
measurable parameters of mandibular movements, especially in complex prosthetic re-
constructions. There is a linear statistic relationship between the SCI and the ANB angle,
thus, in significant skeletal disproportions, the corrected articulating parameters should be
applied. Additionally, the use of individualized values is especially important for patients
with lowered adaptation capacities.
J. Clin. Med. 2022, 11, 2664 11 of 13

Author Contributions: Conceptualization, A.L. and J.K.-J.; methodology, A.L. and J.K.-J.; investiga-
tion, A.L. and J.K.-J.; data curation, A.L., J.K.-J., and K.M.-M.; writing—original draft preparation, A.L.
and K.M.-M.; writing—review and editing, A.L., K.M.-M., and J.K.-J.; supervision, J.K.-J.; funding
acquisition, A.L. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by the Medical University of Warsaw, grant number (1S12/PM4/18).
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board (or Ethics Committee)—the Bioethics
Committee at the Medical University of Warsaw (KB/189/2017) for studies involving humans.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in the study are available on reasonable request
from authors of this article.
Acknowledgments: We would like to thank Marcin Kosiński from the Faculty of Mathematics and
Information Science, Warsaw University of Technology for the statistical analysis.
Conflicts of Interest: The authors declare no conflict of interest.

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