Investigation of The Precision of A Novel Jaw Tracking System in Recording Mandibular Movements: A Preliminary Clinical Study

Journal of Dentistry 146 (2024) 105047
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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent
Investigation of the precision of a novel jaw tracking system in recording

mandibular movements: A preliminary clinical study
Francesco Grande a, c, *, Luca Lepidi b, Fabio Tesini c, Alessio Acquadro c, Chiara Valenti d,
Stefano Pagano e, Santo Catapano f
a
PhD student at Politecnico of Turin, Turin Italy
b
Adjunct Professor Gnathology, University of Ferrara, Ferrara Italy
c
University of Ferrara, Ferrara Italy
d
PhD student at University of Padua, Padua Italy
e
Chief-Professor Dental Materials, Oral Prosthodontic, University of Perugia, Perugia, Italy
f
Chief-Professor Dental Materials, Oral Prosthodontic, University of Ferrara, Ferrara, Italy
A R T I C L E I N F O A B S T R A C T
Keywords: Objectives: This preliminary study aimed to clinically assess the precision of a novel optical jaw tracking system
Functional mandibular movement (JTS) in registering mandibular movements (MMs) of protrusion and mediotrusion.
Jaw tracking system Methods: Twenty healthy participants underwent recordings using Cyclops JTS (Itaka Way Med) for functional
Kinesiography
MMs of protrusion and laterotrusion by two trained clinicians. Each subject performed five registrations at
Jaw movement recording, Computer aided
design
different times according to a standardized pattern within one-month period. The angulations of protrusive and
Dynamic technical modeling mediotrusive functional paths within the first 2 mm from the maximal intercuspal position (MIP) were calculated
for each trace, using a data software for angle measurements. Descriptive statistics were used to assess the
repeatability of the recordings for each participant and MM. Additionally, inferential statistics were carried out
on standard deviation values obtained (α=0.05).
Results: The overall precision for all the patients was 7.07±3.37◦ for the protrusion angle, 5.24±2.24◦ for right
laterotrusion and 5.14±3.06◦ for left laterotrusion angles. The protrusion angle ranged from 3.08◦ to 13.57◦ ,
while the right and left laterotrusion ranged from 1.82◦ to 9.42◦ and from 1.58◦ to 10.59◦ , respectively. No
statistically significant differences were observed between different functional MM types and gender (p > 0.05).
Conclusions: Recordings functional MMs of mediotrusion and protrusion using Cyclops JTS showed consistent
repeatability, regardless of gender and functional MM type. The results revealed non-negligible variations that
may be due to the patients’ abilities to precisely reproduce jaw movements or to the operator’s ability to
consistently connect the kinesiograph.
Clinical significance: Capturing functional MMs digitally and importing the data into dental CAD software is
essential for virtual waxing in prosthetic rehabilitations to design a functionalized adapted occlusion. Estab
lishing the repeatability of MM recordings by a JTS is a crucial step in better understanding this novel JTS in the
market. This process could facilitate the interpretation of cusp angles, aid in CAD dynamic technical modeling,
and enhance clinical data communication between clinicians and technicians in a modern workflow.
1. Introduction speeching [2,3]. However, limitations in correlating MMs with teeth

contacts during clenching and parafunction, coupled with speculative
Traditionally, mandibular movements (MMs) were captured by aims, have resulted in decreased interest in prosthodontics [4].
kinesiograph systems, which required a writing stylus to record The advent of digital jaw tracking systems (JTSs) has introduced safe
mandibular path [1]. Kinesiographs enabled the assessment of 3D and non-invasive techniques for recording MMs [5,6]. These systems
mandibular border movements and their analysis during chewing and utilize various technologies such as stereophotogrammetry [7],
Abbreviations/acronyms: JTS, Jaw tracking system; MMs, mandibular movements; MIP, maximal intercuspal position; CAD, Computer Aided Design.
* Corresponding author: Politecnico of Turin, University of Ferrara, Corso Duca Degli Abruzzi 24 10129, Turin, Italy.
E-mail addresses: [email protected], [email protected] (F. Grande), [email protected] (F. Tesini).
https://doi.org/10.1016/j.jdent.2024.105047
Received 27 March 2024; Received in revised form 3 May 2024; Accepted 5 May 2024
Available online 6 May 2024
0300-5712/© 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Descargado para Anonymous User (n/a) en La Salle University de ClinicalKey.es por Elsevier en octubre 03, 2024. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
F. Grande et al. Journal of Dentistry 146 (2024) 105047
optoelectronics [8], ultrasound [9], and electromagnetic waves [10]. • absence of any history of craniofacial trauma, no presence of
Modern dental software’s capability to integrate data from cone beam congenital or acquired craniofacial anomalies;
computed tomography, intraoral scanner, face scanner and digital JTSs • no temporomandibular disorders;
offers the potential to create a 4D virtual patient [11–14]. This repre • not requiring any prosthetic, conservative, gnathological
sents the initial step in planning and designing complex prosthetic re rehabilitation;
habilitations, such as complete arch implant prostheses or restorations • completely dentate patients with a stable maximal intercuspal po
for severely worn dentitions [15–17]. This non-invasive digital plan can sition (MIP).
be easily shared through network-mediated communication tools,
facilitating simultaneous discussions between clinicians and techni Exclusion criteria were:
cians. Adjustments can then be made based on patient’s aesthetic pref
erences [11–13]. Nowadays, the main clinical expectation of digital JTSs 1. patients who had undergone underwent to prosthetic and conser
is to capture maxillomandibular relationship and MMs during functional vative therapies on the posterior teeth and/or gnathological therapy;
tasks. This facilitates the fabrication of functionalized dental prostheses 2. presence of deep bite and overbite > 3 mm;
with adapted occlusion and articulation [18–22]. Functionalized oc 3. patients with second or third molar and canine Angle class and with
clusion could play a crucial role in prosthodontics, potentially reducing restricted range of mandibular motion.
errors during CAD and manufacturing phases of prosthetic devices [21].
Accurately replicating MMs in a virtual environment depends on factors Twelve patients were excluded after the first visit because they did
such as best-fit alignment data, which minimizes occlusal adjustments not meet the inclusion criteria (Table 1). So, the final sample size con
after restoration delivery [23,24]. This accuracy is crucial for ceramic sisted of 100 tracings from twenty patients (10 men and 10 women). The
and new hybrid materials, preserving their mechanical and aesthetic method adopted consisted in a first clinical phase conducted by the two
integrity [25,26]. expert operators (FG, SP) that performed all the patient recordings with
The repeatability of mandibular motion and the range provided by one optical JTS followed and a second phase of data processing con
the patient during the registration phase with JTSs are crucial for CAD ducted by a blinded operator (LL).
prosthetic design [27–30]. Among the various MMs, the first 2 mm of the The same two trained operators in JTS recordings (FG, SP) performed
mediotrusion and protrusion, evaluated in frontal and sagittal planes, all the registrations using Cyclops© (ITAKA Way Med, Venice, Italy)
are particularly interesting for digitally projecting the inclination, which is a photometric JTS. In order to standardize the recordings and to
length, position, and thickness of tooth cusps and pits [3,31,32]. In in reduce the influence of external factors, all the recordings were per
dividuals with healthy dentition, this portion of the functional MMs formed under the same environmental conditions: 23 ◦ C with 45 % of
appears to be influenced more by the opposing tooth surfaces than by humidity and a room artificial lighting conditions of 1000-lux measured
the anatomy of the temporomandibular joint [3]. A recent study [21] with a digital light meter (Digital light meter LX1010BS; Dr. Meter) and
demonstrated that occlusal design based on patient-specific motion was a white spectrum color temperature (4100 K) which reflects the clinical
more effective in restoring natural anterior tooth guidance. However, room lighting conditions defined by the ISO [34].
precision in MMs registrations remains unaddressed. Given the influence An image summarizing the study design is shown in Fig. 1.
of the neuromuscular system on functional MMs [32], assessing their
repeatability is clinically significant. Previous studies have evaluated
the repeatability of MMs during masticatory cycles [30] and mandibular 2.2. Optical tracking recording using Cyclops©
border movements [3,28,29] finding significant variability across
participants. This JTS consists of two components: hardware and software. The
However, to the best of author’s knowledge, no one has evaluated hardware measuring system is composed by a capture source provided
the precision in recording functional MMs using Cyclops© optical JTSs of stereo-vision cameras and by several accessories provided of sensors
(ITAKA Way Med, Venice, Italy). This device employs a camera to track
the position of markers attached to the patient’s mandible in relation to Table 1
additional markers placed on a patient’s head mounter. In this manner, Inclusion and exclusion criteria.
the JTS can map MMs and make measurements based on image analysis Initially recruitment between February 2021 and June 2023: 32 patients
through marker tracking methods [33]. This preliminary study aimed to
Inclusion criteria Exclusion criteria
investigate the repeatability (precision) of recordings of functional MMs
(protrusion and mediotrusion) in healthy subjects using this novel JTS. Good systemic health status Deep bite
No previous diagnosis of Temporo < 18 years old
Mandibular Disorders (TMDs)
2. Material and method Presence of all teeth groups (incisive, > 65 years old
canines, premolars and molars)
2.1. Study design Willingness to understand the Rehabilitated with a removable total/partial
procedure and give informed denture
consent
Thirty-two participants were initially recruited between February First molar and canine class Ongoing orthodontic treatment (finished
2021 and June 2023. Within this initial sample, twenty subjects were treatment >6 months)
ultimately enrolled in the study (n = 20). Participants were recruited on Acute oral health issue (caries, odontogenic
a voluntary basis from students and dentists within the dental clinic of abscess, odontogenic phlegmon)
Acute/chronic pain of masticatory and facial
our University. All participants were informed about the study proced muscles
ures, and informed consent was obtained and signed. This study fol Primary headaches
lowed the principles laid down by the World Medical Assembly in the Chronic pain (pain >3 months) neck,
Declaration of Helsinki of 2008 regarding medical protocols and ethics. shoulders or back
Previous brain injuries
Each enrolled patient was assigned a consecutive number to ensure
Facial cleft lips/palate
anonymity, and their data were securely stored in a computer chart. Impaired salivary flow because of drugs or
Specific inclusion and exclusion criteria were employed to select the systemic conditions
patient sample for the study. The inclusion criteria for the study were: Neurological disorder with impaired motor
capabilities and affecting cranial nerves
Final patients sample basing on inclusion and exclusion criteria: 20
• voluntary healthy patients (ASA 1) aged between 18 and 65 years;
Fig. 1. Graphical representation of the study design.
that are reported as follow: Body, Zhermack, Badia Polesine, Italy) only for the maxillary posi
The hardware measuring system is composed of a capture source tion recording;
provided with cameras and several accessories provided with sensors, as
follow (Fig. 2): The stabilization of the “mandifork” to the teeth and the absence of
pre-contact or interferences with the antagonist during the MMs were
- A lower fork called “mandifork” which was adapted to the vestibular checked.
surfaces of mandibular teeth with bisacrylic resin (Acrytemp, Zher Then, each participant was dressed wore a black cap and sheet to
mack, Badia Polesine, Italy) and used as the mandibular tracker prevent interference with the recording sensor caused by white clothing
(Fig. 2a); or hair, based on the instructions provided by the manufacturer. The
- A “Triskel” that was hooked by magnets to the "mandifork", "byte participant seated at approximately 40 cm in front of the camera and
fork" and “upper positioner” (Fig. 2b); MMs were recorded in natural head position (Fig. 2d).
- An “upper positioner” that was fixed to the subject head as the head Before each recording, participants were instructed to perform free,
frame (Fig. 2c); quick and repeated MMs for 10–15 s with maximum excursion avoiding
- A “bytefork” that was adapted to the occlusal surfaces of the maxil any uncertainty in both contactless and tooth contacts. This was done to
lary teeth using a polyvinylsiloxane material (Hydrorise Medium prevent misperception and ensure self-awareness and individual re
cordings free from operator conditioning or manipulation.
Fig. 2. a) The Mandyfork of the Cyclops system adapted to the vestibular surfaces of mandibular teeth with bisacrylic resin. b) The Mandyfork connected with the
markers reference (Triskel). c) The upper positioner of Cyclops system connected with its markers reference. d) Patient dressed and in position for functional
mandibular movements recordings.
Subsequently, five recordings were taken at five different times for 3. Results
each participant over a period of one month. The setup time for each
procedure was approximately five minutes. During each recording, Twenty participants were involved in the study, ten males and ten
participants performed brief pro-retrusion and mediotrusion movements females, with a mean age of 27.2 years old. For each patient, five reg
starting from the maximal intercuspal position (MIP) to design the istrations at five different time points were taken. The raw values of the
corresponding tooth guidance. angles (protrusion and laterotrusion angles) calculated for this study
Following the recording, the JTS software (ITAKA Way Med Soft were summarized in table 2. For each participant and for each angle, a
ware, Itaka) provided the traces of the markers points recorded along the descriptive analysis indicating the range, the median, the variance, the
three spatial planes (coronal, sagittal and frontal) (Fig. 3). mean, the standard deviation and the interquartile range was carried out
All data registered and saved were then exported to measurement (Table 3).
software as a JPEG graph image for further processing. The overall precision calculated for all the patients was 7.07±3.37◦
for the protrusion angle, and 5.24±2.24◦ and 5.14±3.06◦ for the later
2.3. Data processing otrusion angles. The protrusion angle ranged from 3.08◦ to 13.57◦ while
the right and left laterotrusion ranged from 1.82◦ to 9.42◦ and from
The JPEG images of the movement tracing graphs were imported 1.58◦ to 10.59◦ The overall precision for men were 6.60±4.03◦ , 4.94
into a software for angle measurements (Angle Meter 360, software App) ±2.1◦ and 3.99±2.33◦ for the protrusion, right laterotrusion and left
(fig. 4). Three different angles were measured on two different move laterotrusion angles respectively. The same for the woman were 7.54
ments trace graphs for each registration. Two angles (on the right and on ±2.68◦ , 5.54±2.45◦ and 6.29±3.31◦
the left side) on the frontal view graph of the mediotrusion movement Figs. 5 show the histograms of the mean±st.deviation related to each
were measured and referred to as “laterotrusion angles” (Fig. 4a). One participant of the protrusion, right and left laterotrusion angles,
angle on the sagittal view of the protrusion movement was measured respectively.
and referred to as “protrusion angle” (Fig. 4b). Kolmogorov-Smirnov Test revealed that data in each group of
The measurements were taken on the first 2 mm of trace registered movements were not normally distributed. The Kruskal Wallis non
from the MIP, which indicate the movement inclination from the parametric test did not demonstrate statistic significant differences be
maximal intercuspation to anterior and lateral left and right edge-to- tween the laterotrusion and protrusion groups (p = 0.52) and between
edge positions. When different traces, corresponding to different an male and females (p = 0.83).
gles, were found in the same graph for the same movement, the choice
was to take the most external trace (the black one) (Fig. 4c). 4. Discussion
2.4. Statistic analysis The purpose of this study was to investigate the precision in re
cordings of three functional MMS (pro-retrusion, right and left medi
Descriptive statistics were used to assess the repeatability (precision) otrusion) captured by using a novel optical JTS, named Cyclops©, at five
of the recordings for each patient and for each MM (protrusion and distinct time points within a one-month period. The descriptive statis
medio-laterotrusion right and left movements). The overall repeatability tical analysis is the only available method that can facilitate an insightful
of the data for each angle was assessed by calculating the mean of the investigation.
standard deviation values obtained from the recording of the 20 patients In this study, the authors chose to measure the angles of MMs traces
(Fig. 5). in the first 2 mm in tooth contact because they are considered the most
Inferential statistics were used to evaluate significant differences interesting from a prosthetic point of view [19,21,31]. The relative
between the laterotrusion and protrusion angles, as well as between precision values of the three functional MMs angles are not so high, but
male and female groups, with a significance level set at p < 0.05. they are comprised in different ranges. This means that, in the subse
quent CAD dynamic modeling phase, the dental technician should
consider a certain degree of imprecision in designing the adapted
functionalized occlusion.
Fig. 3. Report of mandibular movements graphs generated by Cyclops system.
Fig. 4. a) Example of right laterotrusion angle measurement. b) Example of protrusion angle measurement. c) Selection of the external trace: authors opt for the
black line when multiple angles of the same movement were present on the same graph. The red line indicates the most internal trace in the graph representing the
left laterotrusion movement. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 5. Histograms of the mean and standard deviation related to each participant of the protrusion (a), right (b) and left (b) laterotrusion angles.
Table 2
Raw values of the protrusion and laterotrusion angles calculated for each participant during each registration.
Patient Age Sex Registration number Angles
1 24 F Protrusion angle Laterotrusion angles
Ant Post Right Left

1 77 0 47 52
2 61 0 56 57
3 70 0 49 55
4 61 0 49 56
5 60 0 56 54
Table 3 to stabilize the mandifork and especially the patient-device distance

Descriptive analysis generated for each participant for protrusion and latero [49]. While efforts were made to standardize these factors, fluctuations
trusion angles. in the patient-device distance may have occurred during the recording of
Age Sex Registration Angles functional MMs. It is well-documented that for photometric systems, the
number distance between the cameras and the markers can significantly impact
1 24 F Protrusion Laterotrusion registration reliability, especially along the z-axis (x-axis: roll, y-axis:
angle angles
pitch, z-axis: rotation) [50]. For this reason, it’s crucial that data
Ant Dx Sx recorded by the camera come from a source positioned perpendicular to
Max value 77 56 57
the camera and at a constant distance from the object, no >1 meter away
Min value 60 47 52
Median 61 49 55 to minimize the "parallax phenomenon" [35,36].
Variance 55,7 18,3 3,7 Moreover, to achieve accurate recordings, it’s necessary to stabilize
Mean 65,8 51,4 54,8 the "mandifork" to avoid oscillations that could negatively impact pa
Standard 7,46 4,28 1,92 tient perception and limit movements, thereby introducing potential
Deviation
data distortions [27]. For this purpose, we used a bisacrylic resin due to
its ease of application for securing the fork on the vestibular surfaces of
No statistically significant differences were observed among the mandibular teeth, and its ability to be easily relined or removed if
angles measured (protrusion, right and left laterotrusion). However, the necessary. However, an additively manufactured mandibular fork may
protrusion angle group exhibited higher mean and standard deviation be employed to maximize stability during the MMs recordings [51].
values than right and left laterotrusion angles. This may be attributed to The main limitation of the present study is the absence of a reference
the specific recording method used by the Cyclops© JTS. This system or control group, which makes impossible to fully assess the accuracy of
comprises hardware featuring a camera (capture source) positioned on this novel JTS. Due to the in vivo nature of this study, it is impossible to
the frontal plane relative to the moving object (accessories). Conse establish a reference specific to each patient’s functional MM for the
quently, the observed difference could be associated with the "parallax assessment of trueness. Furthermore, variations observed between
phenomenon" or potential operator errors, leading to increased values in values recorded at different temporal instances of MMs may arise from
the sagittal plane [35,36]. both instrument imprecision and inherent biological variability among
However, this remains only a hypothesis as we lack a true reference individual patients. Therefore, this study can only be considered pre
for comparison. In fact it could also be possible that the reason of this liminary, highlighting the need for further comprehensive evaluations of
difference is linked to a human factor, as the muscle groups activated for the accuracy of this novel JTS.
protrusion and laterotrusion movements differ [37–39]. Moreover, the study’s potential was limited by the small sample size
Regarding the impact of human factors on functional MMs re and the inclusion of only healthy participants. In fact, these JTSs are
cordings with optical JTSs [5,27,40], the literature reported also the clinically used for patients undergoing oral rehabilitations. Clinical
individual pattern or patient behavior during the acquisition procedure. conditions such as temporomandibular joint disorders, neuromuscular
In this study, although each participant received clear instructions kinematic dysfunction, variations in natural head position, paraf
multiple times on how to perform the MMs spontaneously and in unctions, unbalanced occlusal contacts, as well as difficulties in intraoral
uninduced way, it’s important to note that the quality of MMs can vary stabilization of the devices due to shortened arches, deep bite, tooth
between individuals due to differences in muscle and joint components absence, and tongue movements, were identified as confounding vari
[37–39]. It is established that mandibular movements involve the co ables [6,27].
ordination of 20 muscle groups, constituting a complex kinematic sys Those points need to be assessed in further research studies.
tem [37–39]. The activity levels of the masticatory muscle like masseter
and temporalis groups decrease during lateral movements and is not 5. Conclusions
always the same leading to differences in the eccentric MMs [37–39].
Furthermore, the patient’s head posture may have change during the Cyclops© JTS, as a digital kinesiograph, showed consistent precision
recordings, potentially contributing to the inconsistency of the MMs [41, registering mediotrusion and protrusion MMs, regardless of gender and
42]. Factors such as the patient’s self-balance and visual righting re functional MM type. The results revealed non-negligible variations that
flexes may have also influenced the recordings, especially considering may be due to the patients’ abilities to precisely reproduce jaw move
that the system emits a strong white light projected in front of the pa ments or to the operator’s ability to consistently connect the
tient’s face during the registration procedure [43,44]. kinesiograph.
MMs may also vary depending on the patient’s emotional state [45]. Differences in functional MMs recorded at different times by using a
We conducted the registrations over one month to minimize the time JTS should be considered for dynamic CAD modeling. Further re
between recordings and prevent potential changes in the patient’s searches are necessary with a control group to fully assess the accuracy
mouth. However, we did not have information about the emotional state of this JTS.
of the patients during the recordings. Additionally, it is the Authors
opinion that participants may have experienced the ‘white coat effect,’ CRediT authorship contribution statement
which could have introduced differences in the MMs [46].
The intraoperator variability in measuring the angle may have also Francesco Grande: Writing – original draft, Methodology, Investi
played a role [47,48]. When different traces were found in the same gation, Data curation, Conceptualization. Luca Lepidi: Writing – orig
graph for the same movement, the choice was to take the most external inal draft, Data curation. Fabio Tesini: Investigation. Alessio
one to design the angle. This decision was based on our attempt to focus Acquadro: Investigation. Chiara Valenti: Investigation, Formal anal
the angle exclusively on patient movements with teeth in contact. ysis, Data curation. Stefano Pagano: Validation. Santo Catapano:
Consequently, when different traces were found, the choice leaned to Writing – review & editing, Validation, Supervision, Project
wards the outer trace indicating teeth in contact, while inner traces were administration.
interpreted as MMs in disclusion. However, this assumption by the au
thors may not necessarily be accurate. Declaration of competing interest
Some environmental conditions may have influenced the registration
process, such as the light source, ambient temperature, type of resin used The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper. rehabilitation: a technical report, J. Esthet. Restor. Dent. 35 (2023) 1068–1076,
https://doi.org/10.1111/jerd.13058.
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Investigation of The Precision of A Novel Jaw Tracking System in Recording Mandibular Movements: A Preliminary Clinical Study

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Journal of Dentistry 146 (2024) 105047

Contents lists available at ScienceDirect

Investigation of the precision of a novel jaw tracking system in recording

1. Introduction speeching [2,3]. However, limitations in correlating MMs with teeth

Fig. 1. Graphical representation of the study design.

Fig. 3. Report of mandibular movements graphs generated by Cyclops system.

1 24 F Protrusion angle Laterotrusion angles

Ant Post Right Left

Table 3 to stabilize the mandifork and especially the patient-device distance

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