Clinical Oral Investigations (2023) 27:4017–4028

https://doi.org/10.1007/s00784-023-05028-9

RESEARCH

Comparison of the performance of various virtual articulator

mounting procedures: a self‑controlled clinical study
Honglei Lin1 · Yu Pan1 · Xia Wei1 · Yinghui Wang2 · Hao Yu2 · Hui Cheng1,2

Received: 29 January 2023 / Accepted: 16 April 2023 / Published online: 29 May 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Objectives This clinical study aimed to compare the performance of various virtual articulator (VA) mounting procedures
in the participants’ natural head position (NHP).
Materials and methods Fourteen participants with acceptable dentitions and jaw relationships were recruited in this study
registered in the Clinical Trials Registry (#NCT05512455; August 2022). A virtual facebow was designed for virtual mount-
ing and hinge axis measurement. Intraoral scans were obtained, and landmarks were placed on each participant’s face to
register the horizontal plane in NHP. Six virtual mounting procedures were performed for each participant. The average
facebow group (AFG) used an indirect digital procedure by using the average facebow record. The average mounting group
(AMG) aligned virtual arch models to VA’s average occlusal plane. The smartphone facial scan group (SFG) and professional
facial scan group (PFG) used facial scan images with Beyron points and horizontal landmarks, respectively. The cone-beam
computed tomography (CBCT) scan group (CTG) used the condyle medial pole, and horizontal landmarks were applied. The
kinematic facebow group (KFG) served as the control group, and a direct digital procedure was applied using a kinematic
digital facebow and the 3D skull model. Deviations of the reference plane and the hinge axis between the KFG and other
groups were calculated. The inter-observer variability in virtual mounting software operation was then evaluated using the
interclass correlation coefficient (ICC) test.
Results In virtual condylar center deviations, the CTG had the lowest condylar deviations. The AFG showed larger condylar
deviations than PFG, SFG, and CTG. There was no statistically significant difference between the AFG and the AMG and
between the PFG and the SFG. In reference plane deviations, the AMG showed the largest angular deviation (8.23 ± 3.29°),
and the AFG was 3.89 ± 2.25°. The angular deviations of PFG, SFG, and CTG were very small (means of each group < 1.00°),
and there was no significant difference among them. There was no significant difference between the researchers, and the ICC
test showed moderate to excellent reliability for the virtual condylar center and good to excellent reliability for the reference
plane in the operation of the virtual mounting software.
Conclusions CBCT scan provided the lowest hinge axis deviation in virtual mounting compared to average mounting, face-
bow record, and facial scans. The performance of the smartphone facial scanner in virtual mounting was similar to that of
the professional facial scanner. Direct virtual mounting procedures using horizontal landmarks in NHP accurately recorded
the horizontal plane.
Clinical relevance Direct digital procedures can be reliably used for virtual articulator mounting. The use of a smartphone
facial scanner provides a suitable and radiation-free option for clinicians.

Keywords Virtual articulator mounting · Natural head position · Facial scan · Cone-beam computed tomography ·
Kinematic digital facebow

Introduction
Honglei Lin and Yu Pan contributed equally to this work. With the advent of digital systems, the use of virtual artic-
* Hui Cheng
ulator (VA) is becoming increasingly popular, replacing
ch.fj@fjmu.edu.cn traditional mechanical articulator (MA) [1]. In a virtual
environment, the VA represents the temporomandibular
Extended author information available on the last page of the article

13
Vol.:(0123456789)
4018
joints and jaws, onto which virtual maxillary and man-
dibular arch models can be attached to simulate mandib-
ular movements [2, 3]. Accurate mounting of the arch
models onto the VA is crucial for the correct simulation
of individual jaw relations [4]. Before mounting, a ref-
erence plane must be identified, passing through three
arbitrary or anatomical points, including two posterior
landmarks determining a terminal transverse hinge axis
and one anterior landmark indicating the direction of the
reference plane. The choice of reference plane is based
on the VA of the CAD software and the clinical require-
ments [5]. As a result, various VA mounting procedures,
including direct or indirect digital workflows, have been
reported [6, 7]. However, studies comparing the accuracy
of virtual mounting procedures are sparse.
The indirect digital workflow involves traditional
mechanical facebow and articulator mounting procedure,
followed by the transfer of digital data to the VA using a
desktop lab scanner (DLS) [6-8]. However, this procedure
is time-consuming and may be inaccurate due to gypsum
expansion and occlusion registration material deforma-
tion [9, 10].
Many fully digital approaches have been introduced. The
simplest direct digital workflow is average virtual mount-
ing, which uses the concepts of the Balkwill angle and the
Bonwill triangle. Virtual arch models are aligned to VA’s
average occlusal plane. However, a previous study found
that average virtual mounting was less accurate than other
procedures [7].
Some researchers have used professional 3D facial scan-
ners to mount virtual arch models onto a VA by matching
cutaneous landmarks in 3D facial photographs [7, 11-15].
However, since professional facial scanners are not widely
available in most dental clinics and labs, other researchers
have attempted to replace them with mobile devices such as
tablets and smartphones with 3D sensor cameras [16]. Previ-
ous studies have suggested that smartphone facial scanners
can meet the requirements of clinical work but are less accu-
rate than professional facial scanners [17-20]. Nonetheless,
the accuracy of using a smartphone facial scanner for virtual
mounting has not been studied yet.
Cone-beam computed tomography (CBCT) scans with
a large field of view (FOV) have also been used for vir-
tual mounting [9, 21, 22]. This technique is not suitable for
simple prosthodontic or orthodontic cases but is useful for
complex interdisciplinary cases [23, 24]. Some studies have
chosen Bergstrom’s point as an arbitrary posterior reference
point [5, 9]. However, in 3D bony structures, the terminal
transverse hinge axis can be located simply by passing
through the left and right condyle medial poles. Few stud-
ies have used this approach, and its accuracy has not been
investigated [22, 25].
13
Clinical Oral Investigations (2023) 27:4017–4028
Kinematic digital facebows, the latest technology today,
record the exact mandible movement paths through ultra-
sound impulses or optical technology [1]. Some CAD soft-
ware systems can support the assembly of completely adjust-
able (CA) VAs by incorporating data from digital facebows.
This fully digital workflow can introduce patient-specific
movements into virtual dental space functionality [26, 27].
In the present study, this workflow was used to identify the
rotational hinge axis via specific mandible movements in
CAD software.
In both 3D facial photographs and CBCT images, the
Frankfort horizontal (FH) plane is commonly used as a ref-
erence to transfer the horizontal plane of the patient to the
articulator, with the infraorbital point as the anterior refer-
ence point [28, 29]. However, it has been shown that the
FH plane is not always truly horizontal when the patient is
in the natural head position (NHP) [30, 31]. The NHP is a
reproducible standardized position of the head in an upright
posture, with the patient looking at a distant point at eye
level, and has been used in virtual mounting [14, 32, 33].
The use of the NHP as the horizontal reference plane was
investigated in the present study.
The purpose of this clinical study was to compare the
deviations in the hinge axis and the reference plane among
different virtual mounting procedures in NHP. For this pur-
pose, six procedures were investigated, including average
facebow record, average mounting, smartphone and pro-
fessional facial scans, CBCT scan, and kinematic facebow
record. The null hypothesis was that no deviations would be
found in the position of the hinge axis and the direction of
the reference plane when using different virtual mounting
procedures.
Materials and methods
Participant selection
The sample size was calculated based on a pilot study with
five participants using G*Power software (G*Power 3.1;
Heinrich Heine University of Dusseldorf, Germany). The
sample size was estimated to be 14 participants (5% type I
error, 90% power, and an effect size of 0.77). Fourteen indi-
viduals (7 females, 7 males, aged between 18 and 25 years
old) were selected to participate in the study. This study was
registered in the Clinical Trials Registry (#NCT05512455).
All participants provided written informed consent approved
by the institutional review board of Fujian Medical Univer-
sity (Code 2021–38). Inclusion criteria included participants
having a full complement of natural teeth (except for the
third molars), class I molar relation, 2–4 mm of overjet, and
stable occlusion. Exclusion criteria included participants
Clinical Oral Investigations (2023) 27:4017–4028
with temporomandibular disorders, poor neuromuscular
control, major restorations, gross attritions, and pregnancy.
Design and assemble a virtual facebow
A virtual facebow with condyle spatial matrix was designed
for virtual mounting and the hinge axis measurement. A vir-
tual articulator (Artex CR; Amann Girrbach AG, Austria)
was used to design a corresponding virtual facebow in CAD
software (DentalCAD; exocad GmbH, Germany). The dis-
tance between the left and right condylar center of Artex
CR was measured to be 110 mm. A cylinder was created in
CAD software (Meshmixer; Autodesk Inc, USA) represent-
ing the hinge axis (174 mm in length and 1 mm in diameter).
Two spheres, each with a diameter of 2 mm and a distance
of 110 mm, were placed symmetrically 32 mm from each
side edge of the cylinder to represent the condyle center.
Fig. 1  Designing a virtual facebow for a virtual articulator (a aligning a virtual hinge axis with the virtual articulator; b the vertical plane, front-
facing plane, and horizontal plane of the virtual articulator; c assembling virtual facebow; d creating the condyle spatial matrix)
4019
The virtual hinge axis was then aligned with the Artex CR,
and the Artex CR’s vertical plane, front-facing plane, and
horizontal plane were combined to form a virtual facebow
(Fig. 1a–c), which was then exported into a standard trian-
gulation language (STL) file. The virtual condyle center on
either side was aligned with the spatial matrix (a matrix of
20 × 20 × 20 mm formed by markers spaced 1 mm apart) in
Meshmixer (Fig. 1d) [25].
Virtual mounting procedures
The experimental design of this study is shown in Fig. 2.
Clinical works for all participants were conducted by a sin-
gle researcher (Y.P.), while virtual mounting procedures
were performed by a separate researcher (H.L.) with CAD
software, reducing operator variation. To obtain virtual
arch models for each participant, maxillary and mandibular
13
4020 Clinical Oral Investigations (2023) 27:4017–4028

Fig. 2  Flowchart illustrating direct and indirect digital workflows for virtual mounting

13
Clinical Oral Investigations (2023) 27:4017–4028
arches were scanned using an optical intraoral scanner
(TRIOS; 3Shape A/S, Denmark) and exported as polygon
file format (PLY) files. Horizontal landmarks were placed
on each participant’s face to register the horizontal plane of
the participants in NHP (Fig. 2). The following steps were
performed: (1) Fix a plane mirror to the wall and ensure
that it is in the true vertical plane. Then, set up a 3D lev-
eling laser (Line laser GLL 3–80 P; Robert Bosch GmbH,
Germany) on a tripod. The laser should face the side front
of the participant, to prevent laser exposure to the eyes. (2)
Instruct the participant to stand comfortably in front of the
mirror, look straight into their own reflected image, and tilt
their head forward and backward with gradually decreas-
ing amplitude. The goal is to find a comfortable position of
natural balance [14, 34]. (3) Make landmarks on the face
with silicon nitride ceramic balls (­ Si3N4, 2 mm in diameter;
Boken BKD Bearing GmbH, Germany), which are visible
on CBCT and facial scan images.
In the average facebow group (AFG), the following
steps were taken, which correspond to the flowchart shown
in Fig. 2: (1) Perform an average facebow (Artex Rotofix;
Amann Girrbach AG, Austria) recording on the subject. (2)
Mount 3D-printed arch models on a fully adjustable articu-
lator (Artex CR; Amann Girrbach AG, Austria) [6, 7, 9].
The 3D-printed models mounted in the articulator were opti-
cally scanned using a DLS (Auto Scan-DS-MIX; Shining
3D, China). (3) Transfer the data into CAD software, and
automatically align virtual models with the VA, achieving an
indirect digital virtual mounting. (4) Import a virtual face-
bow aligned with the VA, and create an AFG composite
model, including virtual facebow and virtual arch models.
In the average mounting group (AMG), the following
steps were taken, which correspond to the flowchart shown
in Fig. 2: (1) Align the virtual arch models with the Artex
CR VA's occlusal plane according to CAD software-guided
markings on the incisal edge of the mandibular central inci-
sor and the mesiobuccal cusp tips of the mandibular first
molars [7], achieving an average mounting. (2) As with the
AFG, create an AMG composite model after importing a
virtual facebow.
Both the smartphone facial scan group (SFG) and the
professional facial scan group (PFG) followed the same
direct digital workflow, except for the type of facial scan
devices used. The steps were as follows (Fig. 2): (1) Capture
the facial soft tissue contours and horizontal landmarks at
the participant’s intercuspal position by using a facial scan-
ner (Bellus3D Dental Pro; Bellus3D GmbH, USA) and a
smartphone (iPhone 13 Pro; Apple, Inc., USA) with a 3D
scan application (Hege 3D scanner; from Apple App Store,
developer: Marek Simonik) [4, 17]. A 3D-printed facebow
fork was used to superimpose the facial scan images with
intraoral digital scans (Fig. 2) [12]. (2) Mark the bilateral
Beyron points (13 mm anterior to the posterior margin of
4021
the tragus of the ear on a line from the center of the tra-
gus extending to the outer canthus of the eye) on the facial
skin [15], and a virtual hinge axis was placed through the
two located Beyron points to represent the arbitrary hinge
axis. (3) Align a virtual facebow with the facial scan images,
making the reference plane parallel to the horizontal land-
marks and making the vertical plane through the midline
of the face. (4) Create SFG and PFG composite models,
respectively, including facial scan, virtual arch models, and
virtual facebow. (5) Align the virtual facebow of the com-
posite model with the vertical plane, front-facing plane,
and horizontal plane of the VA, achieving individual virtual
mounting by facial scans.
In the CBCT scan group (CTG), the steps were as follows
(Fig. 2): (1) A full-face CBCT scan (i-CAT FLX; DEXIS
Dental Imaging Technologies Corporation, USA) with hori-
zontal landmarks was performed on each participant. (2) The
CBCT data were digitized to form 3D craniomaxillary and
mandibular models using 3D Slice, an open-source software
[35]. (3) Align 3D craniomaxillary and mandibular models
with virtual arch models by using the iterative closest point
algorithm in CAD software. (4) Place a virtual hinge axis
through the left and right condyle medial pole to represent
the hinge axis. (5) Align a virtual facebow with the 3D skull
model, making the reference plane parallel to the horizontal
landmarks and making the vertical plane through the mid-
line of the 3D skull model. Create a CTG composite model
including a 3D skull model, virtual arch models, and virtual
facebow. (6) As with the facial scan group, align the vir-
tual facebow of the CTG composite model to the VA, thus
achieving an individual virtual mounting by CBCT scan.
In the kinematic facebow group (KFG), the steps were
as follows (Fig. 2): (1) Train participants to practice small
opening and closing movements, with a range of move-
ment less than 20 mm, and to keep mandibular retraction
during movement. (2) Record the participant’s opening
and closing movement trajectories five times by using the
kinematic digital facebow (JMAnalyser + ; Zebris Medical
GmbH, Germany), and export data as extensible markup
language (XML) files and jawmotion format files [4]. (3)
The virtual arch models were automatically mounted onto
the VA of CAD software after loading the jawmotion file
(Fig. 3a). (4) The position of the skull model in the VA
was observed and judged to be correct by superimposing the
3D skull model with the arch models (Fig. 3b). The follow-
ing steps were employed to check and correct the position
(Fig. 4): (a) the virtual arches were taken as fixed models,
and the 3D craniomaxillary and mandibular models were
located in the VA by superimposing to the upper and lower
arch, respectively. (b) Two virtual facebows with the spatial
matrix that had already been positioned with the VA were
imported, creating two composite models, one including
a craniomaxillary model and virtual facebow, and another
13
4022
Fig. 3  Automatically mounting the virtual arch models after loading the jawmotion file of KFG (a). A 3D skull model in the virtual articulator (b)
including a mandibular model and virtual facebow. (c) The
digital facebow data (XML file) was loaded in CA VA to
simulate individual jaw small opening and closing move-
ments. The spatial matrix of the craniomaxillary model was
stationary, while the spatial matrix of the mandibular model
was rotating with movements (Fig. 4a). The temporoman-
dibular joint was pulled by the lateral pterygoid muscle in
the opening movement, so the rotation center of the spatial
matrix was judged in the small closing movement. In five
repeated measurements, during the small closing movement,
when the rotation center overlapped with the center position
of the space matrix (Fig. 4b), this measurement was judged
as the ideal state and this center position would be selected
as the terminal transverse hinge axis position. (d) The refer-
ence plane of the virtual facebow was adjusted to be parallel
to horizontal landmarks (Fig. 4c). After correcting the posi-
tion, create a KFG composite model and align it with the
VA, achieving an individual virtual mounting (Fig. 4d), as
the reference to compare with other mounting procedures.
Deviation measurement
Using the KFG composite model as the fixed model, six
composite models of virtual mounting procedures were
superimposed by aligning the virtual arch models (Figs. 2
and 5). The distance deviations of the virtual condyle center
and the angle deviations of the reference plane between the
KFG and other groups were then calculated (Fig. 6). To
minimize operator variation, all measurements were per-
formed in triplicate by a single researcher (X.W.). To assess
the inter-observer variability in virtual mounting software
13
Clinical Oral Investigations (2023) 27:4017–4028
operation, three researchers (H.L., Y.P., and X.W.) indepen-
dently performed virtual mounting procedures and meas-
urements on partial data from five participants using CAD
software.
Statistical analysis
Statistical analysis was performed by using SPSS software
(SPSS Statistics v26.0; IBM Corp, USA) at a significance
level of p = 0.05. The data were submitted to the Shap-
iro–Wilk test to check for the assumption of normality, the
distance deviations data were not rejected, and the angle
deviations data were rejected. A two-way repeated measures
analysis of variance (ANOVA) was performed to determine
the significant differences in the distance deviations of the
virtual condyle center, six virtual mounting procedures were
within-subjects factors, and the left and right condyle cent-
ers were between-subjects factors. The Greenhouse–Geisser
correction was used to correct for violations of sphericity in
repeated measures ANOVA. A related-samples Friedman’s
test (nonparametric test) was performed to determine the sig-
nificant differences in the angle deviations of the reference
plane. Post hoc comparisons were undertaken with Bonfer-
roni correction. To evaluate inter-observer variability in vir-
tual mounting software operation, ANOVA was performed
among the three researchers, and interclass correlation coef-
ficient (ICC) estimates were used to evaluate the variability.
ICC values and their corresponding 95% confidence inter-
vals (CI) were calculated based on a mean-rating (k = 3),
absolute-agreement, 2-way random-effects model. Based
on the 95% CI of the ICC estimate, values less than 0.50,
Clinical Oral Investigations (2023) 27:4017–4028
Fig.4  Steps to check and correct the position of the virtual facebow
(a small opening motion simulation in CA VA; b selecting the hinge
axis of rotation without translation as the terminal transverse hinge
axis position; c adjusting the reference plane of the virtual facebow to
between 0.50 and 0.75, between 0.75 and 0.90, and greater
than 0.90 were interpreted as indicating poor, moderate,
good, and excellent reliability, respectively [36].
Results
Virtual condylar center deviations
Virtual condylar center deviations are reported in Table 1.
The results of two-way repeated measures ANOVA indi-
cated that no interaction between virtual mounting pro-
cedures and left and right condyles (p = 0.62). However,
4023
be parallel to horizontal landmarks and then creating a KFG compos-
ite mode; d aligning the KFG composite model with VA by aligning
the vertical plane, front-facing plane, and horizontal plane of the VA)
virtual mounting procedures, as within-subjects factors,
had a significant effect on the virtual condylar center
deviations (p < 0.01). Meanwhile, the left and right con-
dyle centers, as between-subjects factors, had no effect on
the virtual condylar center deviations (p = 0.79). Pairwise
comparisons of virtual mounting procedures were adjusted
by using Bonferroni correction (Table 2). The CTG had
the lowest condylar deviations, showing significant dif-
ferences compared with other groups (all p < 0.01). The
AFG showed larger condylar deviations than PFG, SFG,
and CTG (p < 0.05). There was no significant difference
between the PFG and the SFG (p > 0.99) and between the
AFG and the AMG (p = 0.74).
13
4024
Fig. 5  Taking the KFG composite model as a fixed model, superim-
posing 6 composite models of virtual mounting procedures by align-
ing the virtual arch models
Reference plane deviations
Reference plane deviations are shown in Fig. 7. Related-
samples Friedman’s test found that virtual mounting proce-
dures had a significant effect on the reference plane deviation
(p < 0.01). Pairwise comparisons of reference plane deviations
were adjusted by using Bonferroni correction. The AMG
showed the largest angular deviation (8.23 ± 3.29°) and high
variation among participants (from 0.30 to 13.70°), showing
significant differences compared with PFG, SFG, and CTG
(all p < 0.05). The AFG showed 3.89 ± 2.25° angular devia-
tion, which was similar to that of the AMG and the SFG (AFG
vs. AMG: p > 0.99 and AFG vs. AMG: p = 0.27). The angular
Fig. 6  Calculate the angle deviations of the reference plane (a) and the distance deviations of the virtual condyle center (b) between the KFG
and other groups. Use the AMG measurements as illustrations
13
Clinical Oral Investigations (2023) 27:4017–4028
deviations of PFG, SFG, and CTG were very small (means of
each group < 1.00°), and there was no significant difference
among them (all p > 0.99).
Inter‑observer variability in the operation of CAD
software
Figure 8 shows the results of CAD software operation by
the three researchers. Measurements of the virtual condy-
lar center and reference plane, conducted by the research-
ers using the CAD software, did not reveal any statistically
significant differences (p = 0.82 and p = 0.80, respectively).
The ICC value for the virtual condylar center in virtual
mounting software operation was found to be 0.87 (95%
CI: 0.61–0.96), indicating moderate to excellent reliability.
Similarly, the ICC value for the reference plane in virtual
mounting software operation was 0.97 (95% CI: 0.88–0.99),
indicating good to excellent reliability.
Discussion
Most dental CAD systems include VA modules since accurately
articulating dental arches is critical in designing and manufac-
turing dental prostheses. In the present study, the hinge axis and
the reference plane deviations among different virtual mounting
procedures in NHP were compared. Based on the results of
the present study, the null hypothesis for no deviations when
comparing these procedures was rejected as significant differ-
ences were observed among the CTG with other groups, while
the null hypothesis was not rejected when comparing the AMG
with the AFG and the SFG with the PFG.
Clinical Oral Investigations (2023) 27:4017–4028 4025

Table 1  Virtual condylar center Procedures Left condylar Right condylar Total F p Partial η2
deviations (mean ± Std, mm)
AFG 10.13 ± 2.81a 10.55 ± 3.26a 10.34 ± 2.99
AMG 8.23 ± 3.29ab 8.56 ± 2.62ab 8.39 ± 2.92
SFG 6.97 ± 2.30 bc 5.89 ± 2.68 bc 6.43 ± 2.51
PFG 6.57 ± 2.44c 5.97 ± 2.27c 6.27 ± 2.33
d
CTG​ 2.60 ± 1.57 2.92 ± 1.66d 2.76 ± 1.59
Virtual mounting procedures 35.23 < 0.01 0.58
left and right condyles 0.07 0.79 0.00
Virtual mounting proce- 0.51 0.62 0.02
dures × left and right
condyles
Different lowercase letters in a column indicate significant differences in virtual mounting procedures
(p < 0.05), with p values listed in Table 2
The Greenhouse–Geisser correction was used to correct for violations of sphericity in repeated meas-
ures ANOVA. There was no interaction between virtual mounting procedures and left and right condyles
(p = 0.62). The differences in left and right condylar centers were not significant (p = 0.79), while the differ-
ences in virtual mounting procedures were significant (p < 0.01)

The KFG was chosen as the control group since it involved because this method relied only on intraoral landmarks for
identifying the rotational hinge axis, which is considered more mounting without a reference plane involved. The reference
precise [26, 27]. However, a study has shown that the combi- plane’s deviation means that the VA’s occlusion plane direc-
nations of rotational and translational movements of the tem- tion deviates from its position in the human body and may
poromandibular joint cannot be separated from pure rotational lead to the incorrect dynamic occlusal simulation of the VA.
movements, which may result in possible misalignment of the The horizontal plane, the Camper’s plane, and the FH
hinge axis [37]. Therefore, repeated measurements were taken plane are commonly used as reference planes for mounting,
five times for each participant, and the kinematic approach the articulator in CAD software, and clinical settings [5, 38].
was checked and corrected to ensure the best results. However, a study found that using the FH plane to mount
The average virtual mounting workflow is based on the an articulator can be too steep in clinical practice [29]. In
concepts of the Balkwill angle and the Bonwill triangle. this study, the horizontal plane was utilized because an Artex
Inoue et al. [7] found that average virtual mounting was adjustable articulator was used, which takes the horizontal
less accurate than the average facebow record and 3D facial plane as the reference. The direct virtual mounting procedures
scans. The present study also found that there was a high (KFG, CTG, SFG, and PFG) using horizontal landmarks in
variation and deviation in the reference plane direction NHP accurately recorded the horizontal plane of the partici-
pants’ NHP with an error of less than 1°. Lam et al. [14]
presented a digital workflow of registering the patient's hori-
Table 2  Pairwise comparisons of virtual mounting procedures zontal plane in NHP using a stereophotogrammetry device
Pairwise comparisons Adjusted p values and found good repeatability, with positional differences of
less than 1°. Although the procedures for registering the hori-
AFG vs. AMG 0.74 zontal plane used in the present study differed from Lam et al.,
AFG vs. SFG < 0.01* all procedures showed good repeatability. Those procedures
AFG vs. PFG < 0.01* represented user-friendly ways to mount the virtual models in
AFG vs. CTG​ < 0.01* a VA by using the horizontal plane as a reference.
AMG vs. SFG 0.15 The CBCT approach located in Bergstrom’s point was
AMG vs. PFG < 0.05* introduced by Lepidi et al. [9], and it resulted in a 3.78-mm-
AMG vs. CTG​ < 0.01* left and 4.23-mm-right condylar deviation in comparison with
SFG vs. PFG > 0.99 the kinematic approach. Although studies have recommended
SFG vs. CTG​ < 0.01* Bergstrom’s point as the most frequent closeness to the terminal
PFG vs. CTG​ < 0.01* transverse hinge axis [5, 39], the method is still complex and
The p values have been adjusted for multiple comparisons using the prone to error because it relies on external auditory meatus
Bonferroni correction and FH plane localization in digital software. The CTG is an
*
p < 0.05 improved approach that locates the hinge axis to the medial pole

13
4026
Fig. 7  Reference plane deviations. Values marked with different let-
ters were significantly different (p < 0.05). Symbols represent the var-
iation of the data
of the condyle based on the concepts that (1) the medial pole
of each condyle-disk assembly is braced by bone; and (2) the
horizontal axis through the medial pole of the condyle is the
rotation center of the mandible [40, 41]. Using it as the virtual
condyle center may avoid individual and ethnic variations.
However, according to the ALARA principle [23, 24],
CBCT scans are not appropriate for simple cases. Therefore,
this study investigated radiation-free methods by using smart-
phone and professional facial scanners. Li et al. [17] suggested
that smartphone scanners can meet the requirements of clinical
work. In the present study, the deviation of virtual mounting
by the SFG was slightly larger than the PFG, but there was no
statistically significant difference. Facial scan methods located
the hinge axis at the bilateral Beyron points, which are the next
most accurate posterior point of reference after the Bergstrom
point [5, 39]. It is possible that the deviation of soft tissue land-
marks concealed the difference between the two facial scan
methods. 3D facial images could be used for identifying new
condylar soft tissue landmarks in further studies.
In the present study, the inter-observer variability in vir-
tual mounting software operation was assessed by three
Fig. 8  CAD software operation by three researchers. No statistical
difference between the researchers in the software operation of the
virtual cylinder center and the reference plane (p = 0.82 and p = 0.80,
respectively)
13
Clinical Oral Investigations (2023) 27:4017–4028
researchers. The ICC values indicated moderate to excellent
reliability for the virtual condylar center and good to excellent
reliability for the reference plane, indicating that the direct
digital procedures are reliable for virtual articulator mounting.
The indirect digital workflow used an average facebow
(AFG), in which the participants’ horizontal plane was formed
by the external auditory meatus and a point 42 mm inferior to
the nasal locator of the facebow. The traditional facebow still
has practicality in modern restorative practice [38]. However,
this indirect workflow is not a fully digital workflow since
it requires a traditional mechanical facebow and articulator
mounting procedure with additional treatment time [1].
One limitation of this study was the absence of sagittal
and transversal condylar inclination settings for VA. Setting
the condylar inclination of a dental articulator enables the
delivery of prostheses without occlusal interferences [42].
Although individual sagittal condylar inclination (SCI)
settings have been studied using CBCT, facial scan, and
intraoral scan, the transverse condylar inclination (TCI)
setting has not been studied [15, 22, 43, 44]. Therefore,
future studies are necessary to investigate individual SCI
and TCI settings of VA and compare them with kinematic
facebow records.
Conclusion
Within the limitation of this study, the following conclusions
were drawn:
1. CBCT scans in virtual mounting demonstrated the low-
est hinge axis deviation than average mounting, facebow
record, and facial scans.
2. Direct virtual mounting procedures using horizon-
tal landmarks in the natural head position accurately
recorded the horizontal plane.
3. The use of a smartphone facial scanner in direct virtual
mounting provides a suitable and radiation-free option
for clinical dentists.
Abbreviations AFG: Average facebow group; AMG: Average mount-
ing group; ANOVA: Analysis of variance; CA: Completely adjustable;
CAD: Computer-aided design; CAD/CAM: Computer-aided design and
computer-aided manufacturing; CBCT: Cone-beam computed tomog-
raphy; CI: Confidence interval; CTG​: CBCT scan group; DLS: Desk-
top lab scanner; FH plane: Frankfort horizontal plane; FOV: Field of
view; ICC: Interclass correlation coefficient; KFG: Kinematic face-
bow group; MA: Mechanical articulator; NHP: Natural head posi-
tion; PFG: Professional facial scan group; PLY: Polygon file format;
SCI: Sagittal condylar inclination; SFG: Smartphone facial scan group;
STL: Standard triangulation language; TCI: Transverse condylar incli-
nation; VA: Virtual articulator
Acknowledgments Thanks to Prof. Zhijian Hu, Public Health School
of Fujian Medical University, for his guidance on statistics.
Clinical Oral Investigations (2023) 27:4017–4028
Author contribution Conceptualization: Honglei Lin, Yu Pan, Xia
Wei, Hao Yu, Hui Cheng; Methodology: Honglei Lin, Yu Pan, Yin-
ghui Wang, Hui Cheng; Formal analysis and investigation: Honglei
Lin, Yu Pan, Xia Wei; Writing—review and editing: Honglei Lin, Yu
Pan, Xia Wei, Yu Hao; Funding acquisition: Honglei Lin, Hui Cheng;
Supervision: all authors.
Funding This work was supported by the Natural Science Foundation
of Fujian Province (Grant number 2021J01790).
Data Availability The data that support the findings of this study are
available from the corresponding author, Hui Cheng, upon reasonable
request.
Declarations
Ethics approval This study was performed in line with the principles
of the Declaration of Helsinki and registered in the Clinical Trials Reg-
istry (#NCT05512455). Approval was granted by the Ethics Review
Committee for Biomedical Research of School and Hospital of Stoma-
tology, Fujian Medical University, China (Code 2021–38).
Consent to participate Informed consent was obtained from all indi-
vidual participants included in the study.
Conflict of interest The authors declare no competing interests.
References
1. Lepidi L, Galli M, Mastrangelo F, Venezia P, Joda T, Wang HL,
Li J (2021) Virtual articulators and virtual mounting procedures:
where do we stand? J Prosthodont 30(1):24–35. https://​doi.​org/​
10.​1111/​jopr.​13240
2. Bisler A, Bockholt U, Kordass B, Suchan M, Voss G (2002) The
virtual articulator. Int J Comput Dent 5(2–3):101–106
3. Glossary of Prosthodontic Terms Committee of the Academy of
Prosthodontics (2017) The glossary of prosthodontic terms: ninth
edition. J Prosthet Dent 117(5):1–105. https://​doi.​org/​10.​1016/j.​
prosd​ent.​2016.​12.​001
4. Li Q, Bi M, Yang K, Liu W (2021) The creation of a virtual den-
tal patient with dynamic occlusion and its application in esthetic
dentistry. J Prosthet Dent 126(1):14–18. https://​doi.​org/​10.​1016/j.​
prosd​ent.​2020.​08.​026
5. Raghav D, Kapoor K, Alqahtani A, Kola M, Alqahtani F (2016)
Intricate relations and concepts of reference points in prosthodon-
tics: a literature review. Eur J Prosthodont 4(1):1–6. https://​doi.​
org/​10.​4103/​2347-​4610.​182959
6. Ury E, Fornai C, Weber GW (2020) Accuracy of transfer-
ring analog dental casts to a virtual articulator. J Prosthet Dent
123(2):305–313. https://​doi.​org/​10.​1016/j.​prosd​ent.​2018.​12.​019
7. Inoue N, Scialabba R, Lee JD, Lee SJ (2022) A comparison of
virtually mounted dental casts from traditional facebow records,
average values, and 3D facial scans. J Prosthet Dent [Online ahead
of print]. https://​doi.​org/​10.​1016/j.​prosd​ent.​2022.​03.​001
8. Gärtner C, Kordass B (2003) The virtual articulator: development
and evaluation. Int J Comput Dent 6(1):11–24
9. Lepidi L, Chen Z, Ravida A, Lan T, Wang HL, Li J (2019) A
full-digital technique to mount a maxillary arch scan on a virtual
articulator. J Prosthodont 28(3):335–338. https://​doi.​org/​10.​1111/​
jopr.​13023
10. Maestre-Ferrín L, Romero-Millán J, Peñarrocha-Oltra D, Peñarro-
cha-Diago M (2012) Virtual articulator for the analysis of dental
4027
occlusion: an update. Med Oral Patol Oral Cir Bucal 17(1):160–
163. https://​doi.​org/​10.​4317/​medor​al.​17147
11. Solaberrieta E, Mínguez R, Barrenetxea L, Etxaniz O (2013)
Direct transfer of the position of digitized casts to a virtual artic-
ulator. J Prosthet Dent 109(6):411–414. https://​doi.​org/​10.​1016/​
s0022-​3913(13)​60330-3
12. Solaberrieta E, Garmendia A, Minguez R, Brizuela A, Pradies G
(2015) Virtual facebow technique. J Prosthet Dent 114(6):751–
755. https://​doi.​org/​10.​1016/j.​prosd​ent.​2015.​06.​012
13. Lam WY, Hsung RT, Choi WW, Luk HW, Pow EH (2016)
A 2-part facebow for CAD-CAM dentistry. J Prosthet Dent
116(6):843–847. https://​doi.​org/​10.​1016/j.​prosd​ent.​2016.​05.​013
14. Lam WYH, Hsung RTC, Choi WWS, Luk HWK, Cheng LYY,
Pow EHN (2018) A clinical technique for virtual articulator
mounting with natural head position by using calibrated stereo-
photogrammetry. J Prosthet Dent 119(6):902–908. https://d​ oi.o​ rg/​
10.​1016/j.​prosd​ent.​2017.​07.​026
15. Yang S, Feng N, Li D, Wu Y, Yue L, Yuan Q (2022) A novel
technique to align the intraoral scans to the virtual articulator and
set the patient-specific sagittal condylar inclination. J Prosthodont
31(1):79–84. https://​doi.​org/​10.​1111/​jopr.​13403
16. D’Albis G, D’Albis V, Palma M, D’Orazio F, D’Albis G, Cristino
G, Susca B (2021) Orientation of digital casts according to the
face-bow arbitrary plan. Clin Dent Rev 5(13):1–7. https://​doi.​org/​
10.​1007/​s41894-​021-​00103-4
17. Li J, Chen Z, Decker AM, Wang HL, Joda T, Mendonca G, Lepidi
L (2022) Trueness and precision of economical smartphone-based
virtual facebow records. J Prosthodont 31(1):22–29. https://​doi.​
org/​10.​1111/​jopr.​13366
18. Mai HN, Lee DH (2020) Accuracy of mobile device-compatible 3D
scanners for facial digitization: systematic review and meta-analysis.
J Med Internet Res 22(10):1–20. https://​doi.​org/​10.​2196/​22228
19. Amezua X, Iturrate M, Garikano X, Solaberrieta E (2021) Analy-
sis of the influence of the facial scanning method on the transfer
accuracy of a maxillary digital scan to a 3D face scan for a virtual
facebow technique: an in vitro study. J Prosthet Dent 128(5):1024–
1031. https://​doi.​org/​10.​1016/j.​prosd​ent.​2021.​02.​007
20. Amezua X, Iturrate M, Garikano X, Solaberrieta E (2021) Analy-
sis of the impact of the facial scanning method on the precision
of a virtual facebow record technique: an in vivo study. J Prosthet
Dent [Online ahead of print]. https://​doi.​org/​10.​1016/j.​prosd​ent.​
2021.​10.​025
21. Joda T, Gallucci GO (2015) The virtual patient in dental medicine.
Clin Oral Implants Res 26(6):725–726. https://​doi.​org/​10.​1111/​
clr.​12379
22. Yang S, Dong B, Zhang Q, Li J, Yuan Q, Yue L (2022) An indi-
rect digital technique to transfer 3D printed casts to a mechanical
articulator with individual sagittal condylar inclination settings
using CBCT and intraoral scans. J Prosthodont 31(9):822–827.
https://​doi.​org/​10.​1111/​jopr.​13570
23. Jaju PP, Jaju SP (2015) Cone-beam computed tomography: time
to move from ALARA to ALADA. Imaging Sci Dent 45(4):263–
265. https://​doi.​org/​10.​5624/​isd.​2015.​45.4.​263
24. Horner K, O’Malley L, Taylor K, Glenny A-M (2015) Guide-
lines for clinical use of CBCT: a review. Dentomaxillofac Radiol
44(1):20140225. https://​doi.​org/​10.​1259/​dmfr.​20140​225
25. Park JH, Lee GH, Moon DN, Kim JC, Park M, Lee KM (2021) A
digital approach to the evaluation of mandibular position by using
a virtual articulator. J Prosthet Dent 125(6):849–853. https://​doi.​
org/​10.​1016/j.​prosd​ent.​2020.​04.​002
26. Bernhardt O, Küppers N, Rosin M, Meyer G (2003) Comparative
tests of arbitrary and kinematic transverse horizontal axis record-
ings of mandibular movements. J Prosthet Dent 89(2):175–179.
https://​doi.​org/​10.​1067/​mpr.​2003.​10
27. Mazzetto MODMP, Anacleto MADM, Rodrigues CADM, Bra-
ganca RMD, Paiva GD, ValenciseMagri LDM (2017) Comparison
13
4028
of mandibular movements in TMD by means of a 3D ultrasonic
system and digital caliper rule. Cranio 35(1):46–51. https://​doi.​
org/​10.​1080/​08869​634.​2016.​11499​28
28. Bailey JO, Nowlin TP (1984) Evaluation of the third point of
reference for mounting maxillary casts on the Hanau articulator.
J Prosthet Dent 51(2):199–201. https://​doi.​org/​10.​1016/​0022-​
3913(84)​90260-9
29. Pitchford JH (1991) A reevaluation of the axis-orbital plane and
the use of orbitale in a facebow transfer record. J Prosthet Dent
66(3):349–355. https://​doi.​org/​10.​1016/​0022-​3913(91)​90262-U
30. Chow TW, Clark RKF, Cooke MS (1985) Errors in mounting
maxillary casts using face-bow records as a result of an anatomi-
cal variation. J Dent 13(4):277–282. https://d​ oi.o​ rg/1​ 0.1​ 016/0​ 300-​
5712(85)​90021-1
31. Ercoli C, Graser GN, Tallents RH, Galindo D, Ercoli C, Graser
GN, Tallents RH, Galindo D (1999) Face-bow record without a
third point of reference: theoretical considerations and an alterna-
tive technique. J Prosthet Dent 82(2):237–241. https://​doi.​org/​10.​
1016/​S0022-​3913(99)​70163-0
32. Chiu CSW, Clark RKF (1991) Reproducibility of natural head
position. J Dent 19(2):130–131. https://​doi.​org/​10.​1016/​0300-​
5712(91)​90111-B
33. Meiyappan N, Tamizharasi S, Senthilkumar KP, Janardhanan K
(2015) Natural head position: an overview. J Pharm Bioallied Sci
7(Suppl 2):S424–S427. https://​doi.​org/​10.​4103/​0975-​7406.​163488
34. Cooke MS, Orth D, Wei SHY (1988) A summary five factor
cephalometric analysis based on natural head posture and the true
horizontal. Am J Orthod Dentofac Orthop 93(3):213–223. https://​
doi.​org/​10.​1016/​S0889-​5406(88)​80006-4
35. Fedorov A, Beichel R, Kalpathy-Cramer J, Finet J, Fillion-Robin JC,
Pujol S, Bauer C, Jennings D, Fennessy F, Sonka M, Buatti J, Aylward
S, Miller JV, Pieper S, Kikinis R (2012) 3D Slicer as an image com-
puting platform for the Quantitative Imaging Network. Magn Reson
Imaging 30(9):1323–1341. https://​doi.​org/​10.​1016/j.​mri.​2012.​05.​001
36. Koo TK, Li MY (2016) A guideline of selecting and reporting
intraclass correlation coefficients for reliability research. J Chiropr
Med 15(2):155–163. https://​doi.​org/​10.​1016/j.​jcm.​2016.​02.​012
Authors and Affiliations
Honglei Lin1 · Yu Pan1 · Xia Wei1 · Yinghui Wang2 · Hao Yu2 · Hui Cheng1,2
1 2
Fujian Key Laboratory of Oral Diseases & Fujian Provincial
Engineering Research Center of Oral Biomaterial &
Stomatological Key Lab of Fujian College and University,
School and Hospital of Stomatology, Fujian Medical
University, 88 Jiaotong Road, Fuzhou 350004, Fujian, China
13
Clinical Oral Investigations (2023) 27:4017–4028
37. Mehl A (2020) Is it possible to detect a true rotation axis of the
temporomandibular joint with common pantographic methods?
A fundamental kinematic analysis. Comput Methods Biomech
Biomed Engin 23(9):445–455. https://d​ oi.o​ rg/1​ 0.1​ 080/1​ 02558​ 42.​
2020.​17249​75
38. Nagy WW, Goldstein GR (2019) Facebow use in clinical prostho-
dontic practice. J Prosthodont 28(7):772–774. https://​doi.​org/​10.​
1111/​jopr.​12944
39. Beck HO (1959) A clinical evaluation of the arcon concept of
articulation. J Prosthet Dent 9(3):409–421. https://​doi.​org/​10.​
1016/​0022-​3913(59)​90072-1
40. Dawson PE (1985) Optimum TMJ condyle position in clinical
practice. Int J Periodont Restor Dent 5(3):10–31
41. Dawson PE (2006) Functional occlusion: from TMJ to smile
design, 1st edn. St. Louis
42. Bapelle M, Dubromez J, Savoldelli C, Tillier Y, Ehrmann E (2021)
Update on the parameters influencing the adjustment of the sagittal
and transversal condylar inclination of dental articulators. Quintes-
sence Int 53(1):78–88. https://​doi.​org/​10.​3290/j.​qi.​b1702​361
43. Das A, Muddugangadhar BC, Mawani DP, Mukhopadhyay A
(2021) Comparative evaluation of sagittal condylar guidance
obtained from a clinical method and with cone beam computed
tomography in dentate individuals. J Prosthet Dent 125(5):753–
757. https://​doi.​org/​10.​1016/j.​prosd​ent.​2020.​02.​033
44. Hong SJ, Noh K (2021) Setting the sagittal condylar inclination
on a virtual articulator by using a facial and intraoral scan of the
protrusive interocclusal position: a dental technique. J Prosthet Dent
125(3):392–395. https://​doi.​org/​10.​1016/j.​prosd​ent.​2020.​01.​031
Publisher's note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Springer Nature or its licensor (e.g. a society or other partner) holds
exclusive rights to this article under a publishing agreement with the
author(s) or other rightsholder(s); author self-archiving of the accepted
manuscript version of this article is solely governed by the terms of
such publishing agreement and applicable law.
Institute of Stomatology & Research Center of Dental
Esthetics and Biomechanics, School and Hospital
of Stomatology, Fujian Medical University, 246 Yangqiao
Zhong Road, Fuzhou 350002, Fujian, China