Virtual Articulator Software: Accuracy, Usability, and Clinical Applicability: A Systematic Review

Abstract

Introduction and aims

Virtual articulator software platforms have gained popularity in dentistry for simulating dental articulations, but a comprehensive comparison of their accuracy, user-friendliness, and clinical relevance is lacking. This study aimed to evaluate various virtual articulator software platforms, focusing on accuracy, user-friendliness, and clinical applicability.

Methods

A systematic search was conducted across PubMed, Google Scholar, ScienceDirect, the Cochrane Library, and Scopus, following the PICO/PEO strategy for inclusion and exclusion criteria. Studies comparing virtual articulator software platforms up to 2023 were included. Eligible studies were selected, and relevant data were extracted. The quality of the research was assessed using the QUIN tool for in vitro studies and the Mixed Methods Appraisal Tool (MMAT) tool for non-in vitro studies. Likewise, for the certainty of evidence, the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was utilized.

Results

Out of 3,091 initially identified research articles, 17 met the inclusion criteria. The analysis revealed a diverse range of virtual articulator systems, including Panadent, Ortho CAD™, CT, CAD/CAM, PAN 300, and MATLAB program, serving as alternatives to traditional articulators. The virtual articulator software demonstrated efficiency and user-friendliness, highlighting their potential in dental applications.

Conclusion

The diversity of software, platforms, and systems for virtual articulators prevents the formulation of definitive and succinct conclusions. Nevertheless, in a general assessment, virtual articulators demonstrated comparable accuracy and precision when juxtaposed with their traditional counterparts.

Clinical Relevance

Virtual articulator software accurately simulates occlusal relationships and mandibular movements, enhancing dental treatment planning and patient outcomes. These tools integrate easily into clinical workflows, improving communication and personalized care. While further research is needed to standardize assessment methods, virtual articulators show comparable precision to traditional methods, supporting their use in diverse clinical scenarios.

Introduction

Technological advancements play a pivotal role in reshaping traditional practices and enhancing the precision of diagnostic and treatment procedures. From the evolution of digital X-rays to the advent of 3D printing, technological progress has revolutionized the delivery of dental care, enhancing precision, safety, and patient comfort.¹ Traditionally, the study of occlusion and temporomandibular joint (TMJ) movements relied heavily on analog articulators, mimicking jaw movements, but lacked the dynamic adaptability of digital solutions.² In recent years, the utilization of Virtual Articulator Software Platforms has become a point of focus.^{3, 4} These software applications simulate the movements of the TMJ and enable dentists and dental technicians to analyze and plan occlusion in a virtual environment.⁵ Moreover, the virtual articulator within prosthetic and restorative dentistry represents a noteworthy application grounded in virtual reality.^6,7 This promises to alleviate the constraints associated with mechanical articulators,⁸ substantially reducing their limitations.^9,10 By simulating authentic patient data, this innovative tool facilitates a comprehensive analysis encompassing static and dynamic occlusions and considerations related to jaw relations.⁶ Several authors have documented digital methods employed to construct virtual arch models within a virtual articulator. Their focus has been on various aspects, including virtual facebows¹¹ and digital occlusal registration.⁵ Initially, the physical dental articulator underwent scanning using the ATOS Compact three-dimensional scanner. Subsequently, the processing phase took place using reverse engineering Geomagic software, enabling the extraction of essential geometric elements.¹² As the dental industry embraces digital solutions, it becomes imperative to scrutinize and compare these virtual articulator software platforms' accuracy, user-friendliness, and clinical applicability.^13,14

Moreover, accuracy is paramount in any dental procedure, and virtual articulator software platforms aim to provide a more precise and reproducible method for studying and adjusting occlusions.¹⁵ The dynamic motions observed on the virtual articulator were demonstrated to be as accurate and precise as those on the mechanical articulator. In instances of variance, these discrepancies measured less than 100 µm, suggesting that such deviations may not have clinical significance.¹⁶ Although accuracy is a non-negotiable aspect, the ease of use of virtual articulator software platforms is equally critical.⁵

Virtual articulator software platforms play a pivotal role in prosthodontics by revolutionizing the precision and efficiency of treatment planning and execution.¹⁷ These advanced digital tools enable prosthodontists to analyze and simulate occlusal relationships with unparalleled accuracy, thereby facilitating the creation of customized treatment plans.¹⁸ The 3D visualization capabilities allow for a comprehensive understanding of the patient's oral anatomy, aiding the design and placement of dental prostheses.¹⁹ By integrating with computer-aided design/computer-aided manufacturing (CAD/CAM) systems, virtual articulator software ensures a seamless transition from digital planning to the fabrication of prosthetic restorations, resulting in enhanced workflow efficiency and reduced margin of error.²⁰ This technology improves diagnostic capabilities and fosters interdisciplinary communication among dental specialists, ultimately contributing to the delivery of high-quality, patient-centric prosthodontic care.

Despite the advancements and the growing adoption of Virtual Articulator Software (VAS) in dental practice, existing studies present several limitations. Firstly, many studies focus predominantly on the technical validation of these tools rather than their practical implications in routine clinical settings.3, 4, 5, 6, 7^,9 This narrow focus leaves a gap in understanding how these technologies perform under varied real-world conditions. Furthermore, the literature often lacks a comprehensive comparison across different types of virtual articulators, resulting in a fragmented understanding of which systems offer the best performance across diverse clinical scenarios. Additionally, inconsistencies in findings have been noted, with some studies reporting high efficacy and others noting significant discrepancies in performance outcomes. For example, while Gracco et al (2023)² highlighted the precision of specific VAS systems in controlled settings, Solaberrieta et al (2015)¹⁰ and Lepidi et al (2021)⁷ pointed out operational challenges and accuracy concerns when these systems were employed in complex clinical procedures. These inconsistencies suggest a need for more robust, comparative research that evaluates the effectiveness of different virtual articulators in a broader range of dental treatments.

Virtual articulators come in two distinct types: completely adjustable and mathematically simulated. The Completely adjustable variant captures and replicates precise mandibular movement paths by utilizing an electronic jaw registration system known as the Jaw Motion Analyzer (JMA). A notable example is the DentCAM virtual articulator pioneered at the University of Greifswald.^21,22 Moreover, the software performs computations and presents visualizations for static and kinematic occlusal collisions, which are crucial in designing and correcting occlusal surfaces within CAD systems. Examples of virtual articulators include Kordass and Gartner.⁶ Mathematically simulated virtual articulators emulate and replicate an articulator's movements through mathematical simulations of articulator motion. Examples of such virtual articulators include Stratos 200 and Szentpetery's virtual articulators.²³ Moreover, a consolidated and up-to-date overview of individual software platforms that systematically compares the strengths, weaknesses, and unique features of different virtual articulator solutions is limited.

While previous research has provided foundational knowledge on the efficacy and utility of VAS,^13,19, 20, 21^,25,27,28 significant gaps remain that need to be addressed to optimize their application in dental practice. A primary gap is the lack of comprehensive studies that compare the accuracy and efficiency of different VAS platforms under a variety of clinical conditions. This comparison is crucial for dental practitioners seeking to choose the most effective technology for their specific clinical needs. Moreover, there is insufficient data on the user-friendliness and integration of these systems into existing dental workflows, aspects that are critical for widespread adoption and effective use. Additionally, the impact of VAS on patient outcomes, particularly in terms of procedural efficiency and satisfaction, has been minimally explored, leaving a significant area for research. These gaps highlight the need for a systematic evaluation that not only assesses the technical performance of these tools but also their practical implications in enhancing dental care.

This systematic review aimed to inform decision-making regarding the adoption of virtual articulator software in contemporary dental practices. The research objectives were (1) to evaluate the accuracy of digital articulation analysis, (2) to assess user-friendliness for seamless workflow integration, and (3) to investigate clinical applicability for improved patient outcomes and treatment planning.

Methods

This systematic review adopted the Preferred Reporting Items for Systematic Review (PRISMA) guidelines.²⁴ The protocol used for this systematic review was the registered International Platform of Registered Systematic Review and Meta-Analysis Protocols [Blinded for review].

The search strategy used the PICO/PEO (Participants, Intervention, Comparators or Controls, and Outcome) framework.²⁵ The PICO framework is presented in Table 1.

Table 1.

The PICO framework designed for this study.

PICO Items	Study design
Participants	Patients requiring dental implants.
Intervention	Utilization of virtual articulators in dental implant planning and treatment
Comparison	Conventional methods of using manual articulators in dental implant planning. Evaluating differences in workflow efficiency, precision, and outcomes.
Outcomes	Evaluation of ease of use for clinicians and dental teams. Effectiveness in real-world dental practice settings. Impact on patient satisfaction and procedural efficiency.

Databases such as PubMed, Google Scholar, ScienceDirect, The Cochrane Library, and Scopus were searched using different keywords such as “virtual articulators,” “digital articulators,” “computer-aided articulators,” “digital dental articulators,” “accuracy,” “trueness,” “user friendliness,” “clinical applicability,” and “clinical relevance” (Supplementary Table 1).

Two independent reviewers were involved in the selection of the articles. In the first phase, articles were identified from different databases and removed duplicates. In the screening phase, articles were screened via title and abstracts and irrelevant studies including reviews, case studies were excluded. Remaining articles were further screened via full text assessment and articles were excluded with more focused reasons on the bases of eligibility criteria set. In the last phase, articles were included after following strict eligibility criteria. In case of discrepancies, third reviewer was consulted, and issue was resolved.

There were certain inclusion criteria set for the selection of articles. For instance, the studies included needed to provide a comparative analysis or at least exposure to intervention of different virtual articulator software platforms or applications. Additionally, only articles that reported at least one of these platforms' accuracy, user-friendliness, and clinical applicability were considered. The selected studies encompassed a range of research designs, including in vitro studies, randomized controlled trials (RCTs), cohort studies, and observational studies, to ensure a comprehensive evaluation of the targeted aspects. Studies published in peer-reviewed journals in the English language until 2023 were included.

Similarly, certain exclusion criteria were also set, for instance, studies that did not provide adequate information on at least one of these key parameters (accuracy, user-friendliness, and clinical applicability) were excluded. Additionally, any research lacking a clear methodology or those that primarily focused on aspects unrelated to the specified evaluation criteria were excluded from the review. Case studies, reviews, and non-English articles were excluded.

A standardized data extraction form was created and implemented to enhance data precision and minimize the risk of errors. Any disparities or conflicts arising between the two independent reviewers [Blinded for review] during the data extraction phase were addressed through discussion and mutual agreement. A third reviewer [Blinded for review] was consulted when a unanimous decision could not be made.

Selected studies meeting the inclusion criteria underwent information retrieval, and the data extraction protocol involved various crucial elements. Initially, demographic details such as author information, country of origin, study design, sample size (patients/implants), and virtual articulation used were documented. Additionally, the accuracy assessment characteristics were extracted, including the technique employed for accuracy measurement, dental implant position, and marginal fit measurements. User-friendliness and clinical applicability features were also captured. The protocol was designed to encompass reporting conclusions and identifying and reporting any limitations or potential biases identified in the studies.

For the appraisal of the methodological quality of in vitro studies, QUIN, the quality index tool was used based on 12 items and scored in the response as “yes” (allocated 1-2 points), “no” (allocated 0 points) or “not applicable”.²⁶ and studies scored >70% considered to have low risk of bias (RoB), those between 50-70% were the medium RoB, <50% were the high RoB.²⁶ In contrast, non-in vitro studies underwent evaluation using the Mixed Methods Appraisal Tool (MMAT). Quality scores for these studies were calculated according to the procedure outlined by Charette et al²⁷ The studies were then classified as either low-quality (scoring ≤3) or high-quality (score >3) based on their affirmative responses garnering 1 point and negative responses receiving 0 points, as per the criteria established.²⁸

Articles were included in the systematic review using qualitative analysis. The systematic selection of pertinent literature was guided by the PRISMA checklist methodology, and articles were selected using a rigorous, step-by-step process. For inter-rated reliability, Kappa statistics was used among the two reviewer's selection of studies. For the certainty of the evidence, the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was utilized.²⁹

Results

A comprehensive review of scientific literature was undertaken using various electronic databases (PubMed, Google Scholar, Scopus, ScienceDirect, and The Cochrane Library). All research publications that have been identified were published in prestigious peer-reviewed journals. Following a thorough examination, 3091 relevant articles were initially obtained. Subsequently, 300 duplicate articles were detected and eliminated from the review. The remaining 2791 publications underwent a detailed assessment of titles and abstracts, leading to the exclusion of 2765 articles that were more relevant to the scope of our study. This left 26 articles for further scrutiny, nine of which were removed for various reasons (Figure). Finally, 17 remaining publications were included in this systematic review by the agreement between the two reviewers. Among 26 studies, disagreement was observed in two studies, which were resolved, and consensus was reached. Overall, the inter-rated reliability (Kappa statistics) was 0.82, which showed strong agreement among the two reviewers in the selection of studies.

Fig.

PRISMA flow chart.

Most studies were conducted in the USA,^16,30, 31, 32 China,33, 34, 35, 36 Singapore,^{37, 38} India,^39,40 Australia,⁴¹ Taiwan,³ Israel,⁴² Spain,⁴³ and Germany.⁴⁴ Moreover, most of the studies followed in vitro study design except a few studies followed cross-sectional,⁴³ pilot study,³⁹ mixed designed prospective,³² and controlled clinical trial.^34,36 In terms of sample size, studies have used different types of samples, such as models^{30,32,37,38,42} and patients^16,31,35,36,39, 40, 41^,43, as test subjects. Additionally, most articulators were used for maxillary and mandibular purposes, except for a few studies that used occlusal contact points⁴⁴ and jaw movement.³ Furthermore, different types of software/systems/platforms were used, and each study reported different types, as shown in Table 2, and compared the virtual articulator with traditional/conventional/handmade articulators. Table 2 summarizes various studies focused on features and functionalities related to occlusion analysis in dentistry. Most of the studies primarily centered on occlusion analysis.^3,30, 31, 32^,34,35,38,41, 42, 43, 44 Moreover, Shetty et al⁴⁰ focused specifically on maxillary occlusal cant, while Anusha et al³⁹ concentrated on the occlusal plane. Some studies have explored features related to both maxillary and mandibular occlusal aspects,^16,33,36 with Zhang et al³⁶ specifically delving into intercuspal occlusion (Table 2).

Table 2.

General characteristics of included studies.

Study Reference	Country	Study design	Sample size	Description of subjects	Articulator used for	Software/platform for virtual articulators	Comparison	Features and functionalities
30	USA	In vitro	12 sets of patient's dental model	Single-piece osteotomy	MI position	Cartesian coordinate system	NA	OA
43	Spain	Cross-sectional	One patient	Mandibular left first molar restoration	Maxillary cast	Panadent virtual articulator	Conventional method	OA
40	India	In vivo	30	NA	Maxillary impressions	Two facebow/semi-adjustable articulator systems (Rotofix Artex and Spring-Bow Hanau)	lateral cephalograms	Maxillary occlusal cant
39	India	Pilot study/clinical trial	20 patients	Edentulous patients	Maxillary and mandibular impressions	Semi-adjustable arcon articulators systems (Hanau® Wide Vue with Hanau® Spring Bow and Whip Mix® with Whip Mix® Quick mount facebow)	NA	OP
38	Singapore	In vitro	Five mounted cast set	Fully dentate	Maxillary	CAD-system	(Ceramill Map400 (AG), inEos X5 (SIR), Scanner S600 Arti (ZKN)	OA
42	Israel	In vitro	231 pairs	NA	NA	KaVo PROTARevo	NA	OA
31	USA	In vitro	25	NA	Maxillary and mandibular	OrthoCAD™ software	Intra and extra-oral scanners	OA
16	USA	In vitro	12	Altering condylar settings and pin openings	Maxillary and mandibular	Dental Designer Software (v17.2.1; 3Shape)	Mechanical (ARCON type Artex-CR articulator)	Maxillary and mandibular occlusal
33	China	In vitro	NA	NA	Mandibular movement	PN-300	NA	Maxillary and mandibular occlusal
32	USA	Mixed-designed prospective study	30 pairs of stone dental models	Double-jaw orthognathic surgery patients (1-piece Le Fort I osteotomy)	One-Piece Maxillary surgery	MATLAB program (a three-stage algorithm approach)	Manually articulator	OA
36	China	Controlled Clinical trial	12 patients	A single posterior tooth defect	Maxillary and mandibular arches	Virtual articulator	Traditional	IO
41	Australia	In vitro	Ten patients (30 cases)	Orthognathic cases	Maxillary and mandibular arches	Simplant O and O® (Version 3; Simplant Dentsply Implants, Hasselt, Belgium).	Hand articulated	OA
44	Germany	In vitro	NA	NA	Occlusal contact points	Intraoral scans (IOS CS3600 (CS ScanFlow v.1 4th version), TRIOS 3 (Basic 2019), and CEREC Omnicam (Software version 5.1)	Articulation foil	OA
3	Taiwan	In vitro	NA	NA	Jaw movement	CT	Mechanical	OA
34	China	Controlled clinical trial	14 patients	Acceptable dentitions and jaw relationships	NA	AMG intraoral scans matched virtual arch models to VA's average occlusal plane. The SFG and PFG groups employed Beyron point and horizontal landmark face scans. The CBCT scan group (CTG) employed horizontal markers and the condyle medial pole. KFG was the control group.	Indirect digital procedure	OA
35	China	In vitro	9	Needed crown repair	NA	CAD/CAM	Traditional	OA
37	Singapore	In vitro	10 for each group	Dentate	Maxillary and mandibular master models	Artex CR semi-adjustable articulator system	Splitex Mounting Articulator	Maxillary and mandibular occlusal

MI, maximal intercuspation; OA, occlusion analysis; OP, occlusal plane; CAD, computer aided design; IO, intercuspal occlusion; CT, computed tomography; AMG, average mounting group; SFG, smartphone facial scan; PFG, professional facial scan; CBCT, cone-beam computed tomography; KFG, kinematic facebow group; CAM, computer aided manufacturing; NA, not available.

Table 3 presents a thorough summary of the different assessment methodologies used in several studies on articulator performance. Most studies used measurement error and angle deviation for the assessment of accuracy.^16,31,33 Moreover, other assessment methods include translational and rotational differences and surface deviation,^30,43 Frankfort horizontal plane‑occlusal plane angles,⁴⁰ the mean angle between the occlusal plane and horizontal reference plane from different articulators,³⁹ and inter-arch global distortions and errors,³⁸ while Pietrokovski et al⁴² measured the distance between casts. In addition, differences in midline, canine, and molar relationships were analyzed.³² Overall, the included studies were conducted for the evaluation of accuracy in general for different articulators prepared virtually or traditionally. However, some studies specify accuracy in terms of precision, trueness,^16,38 interchangeability,^37,42 transferability,³⁹ or general performance.^34,36 In terms of accuracy, all studies showed reliable findings and comparable outcomes; however, one study reported negative results, stating that virtual articulator systems were not up to the mark claimed by the manufacturers.³⁷ Moreover, a few studies have reported that virtual articulator systems are efficient, easy to use, and reduce time.^{3,30,32,38,43}

Table 3.

Diverse array of outcomes resulting from the investigated factors.

Study Reference	Accuracy			Efficiency/Ease of use	Clinical applicability and usability	Conclusion	Limitation
	Assessment methods	Assessed parameters	Accuracy outcomes
30	Translational, rotational difference, and surface deviation	Accuracy	Largest translational difference = 0.2 mm ± 0.6 mm. Largest rotational difference = 0.1° ± 1.1°. The average surface deviation = 0.08 ± 0.07	Efficient	Caution is recommended in a clinical setting	Digital dental models can articulate MI positions quickly and precisely.	NA
43	Deviation	Accuracy	Mean deviation = 0.752 mm	Reduce time	Need further study	Under favorable conditions, utilizing a virtual facebow is feasible.	Sample size
40	Frankfort horizontal plane-occlusal plane angles	Accuracy	A mean difference of 1.9° between the Hanau Wide-vue articulator and lateral cephalogram. Artex Amann Girrbach's articulator showed a mean difference of 3.6° compared to the lateral cephalogram.	NA	NA	The Frankfort horizontal plane-occlusal plane angle was more accurate in casts articulated on the Hanau Wide-Vue articulator than the Artex Amann Girrbach articulator.	NA
39	The mean angle between OP and the horizontal reference plane obtained from both types of articulators	Transferability	Hanau Wide Vue and Whip Mix articulator systems demonstrated a significant mean difference of 10.51°, with the Hanau system values consistently lower than those of the Whip Mix system.	NA	NA	The angle that is replicated between OP and the horizontal reference plane differed significantly between the Hanau and Whip Mix systems. Compared to the Whip Mix system, the Hanau system showed values that were more in line with cephalometric measures.	Human errors during the recording of data
38	Interarch global distortions, error	Trueness and precision	The precision of the inEos X5 group was significantly lower than that of the Ceramill Map400 and Scanner S600 Arti groups at interact and interocclusal levels.	Easy to use (all three systems)	NA	All three-model scanner-CAD systems have global distortion < 0.6%. Distortion varied with scanner technology, virtual articulation algorithms, and actual articulators.	NA
42	Distance between casts was measured	Interchangeability	Out of 231 potential pairs of articulators, only 27 pairs were interchangeable (measuring less than 166 µm in all dimensions), while in the remaining 204 pairs, at least one dimension measured larger than 166 µm	NA	To ensure precision in restoration production, it is recommended to consistently use the same articulator in both clinical and dental laboratory settings.	The majority of articulators examined did not satisfy the interchangeability standard of 166 µm.	NA
31	Measurement error, Angle deviation	Accuracy	Only the iTero® (IOCS) and iTero® Element (IOCC) produced articulated models with all interarch measurements within the acceptable range.	NA	Use with caution	Articulated models were accurately produced only by scanners equipped with confocal imaging technology.	Accuracy measurements were measured from points in the vertical dimension only.
16	Angle deviation	Trueness and precision	The only significant difference was in the precision between the two types of articulators (F = 15.134, P = .0008); no statistically significant difference (F = 3.624, P > .05) between the virtual and mechanical articulators in trueness or for all the precision measurements (F = 3.529, P = .07). The one significantly different trueness measurement (F = 9.237, P = .006) occurred at SCI of 10°, and it was less than 100 μm	NA	NA	The virtual articulator demonstrated dynamic movements as accurate and precise as those on the mechanical articulator. In instances of deviations, they were observed to be less than 100 μm, suggesting that these discrepancies may not have clinical significance.	NA
33	Measurement error, Angle deviation	Accuracy	Measurement error<100 um, Angle error within 0.20	NA	NA	PN-300 had good accuracy	NA
32	Differences in midline, canine, and molar relationships	Accuracy	No statistically significant differences were observed between the two methods (F (1,28) = 0.03; P = .87). The mean differences between the two methods were all within 0.2 mm.	Efficient	Fully automatic, no manual data extraction	Results indicated that the articulation of dental models can be achieved accurately, reliably, and automatically through a three-stage algorithm approach.	Its applicability is limited to one-piece maxillary surgery.
36	The number of occlusal contacts, the relative occlusal forces	Performance	The occlusal adjustment times for digital articulator and traditional method crowns were 327 ± 226 seconds and 395 ± 338 seconds, respectively (P > .05). No significant differences were observed in occlusal contacts, occlusal contact distributions, number of occlusal contacts, or relative occlusal forces.	NA	Acceptable	Single-crown repair using a computerized articulator proved successful.	NA
41	Translational differences	Final occlusal planning	Average translational difference= 1.58 mm ±1.14 mm	NA	Need further validation	Results obtained through digital articulation matched those achieved with hand-held methods.	NA
44	Visualization was screenshot and compared	Accuracy	The TRIOS3 by 3Shape demonstrated significant results in sensitivity and accuracy compared to the other tested intraoral scanners (P < .05)	NA	NA	Articulation foil showed occlusal contact sites more precisely than IOS.	NA
3	Differences between the simulated trajectory of the jaw motion and the (measured) real trajectory	Accuracy	The Fréchet distance, indicating the proximity between the tracked mandible movement and the simulated condyle movement, measured approximately 1.7 mm.	Efficient	Feasible for various clinical applications	This virtual articulator is a valuable tool, allowing dentists to gather diagnostic information about TMJ and customize occlusal analysis settings for individual patients.	Laboratory equipment with low accuracy
34	Deviations between the reference plane and the hinge axis	Performance	CTG exhibited the most minor deviations among virtual condylar center deviations, while AFG demonstrated more significant deviations than PFG, SFG, and CTG. No statistically significant difference was found between AFG and AMG, as well as between PFG and SFG. In terms of reference plane deviations, AMG showed the highest angular deviation (8.23 ± 3.29°), and AFG had a deviation of 3.89 ± 2.25°. PFG, SFG, and CTG displayed minimal angular deviations (each group with means < 1.00°), and no significant differences were observed	NA	NA	Digital procedures, such as smartphone facial scanners, offer a reliable and radiation-free alternative for virtual articulator mounting in clinical settings.	NA
35	Occlusal contact points, areas, and the occlusal force percentage peak	Accuracy	The virtual-control group exhibited significantly larger occlusal contact overlapping areas than the mechanical-control group. Additionally, the mechanical group had a slightly higher percentage peak of occlusal force in the tested teeth than the virtual group.	NA	Can provide guidance	A virtual articulator yields superior intercuspal occlusal restoration compared to a mechanical articulator, reducing dynamic occlusal interference for posterior single crowns.	NA
37	Interarch 3D distance distortions (dRR, dRC, and dRL), interocclusal 3D distance distortion (dRM), interocclusal 2D distance distortions (dxM, dyM, and dzM), and interocclusal angular distortion (dqM) relative to the master articulator	Interchangeability	New articulators dRR=4.6 ±21.6 mm to 62.8 ±75.2 mm; prosthodontic residents=56.3 ±47.6 mm to 119.0 ±58.8 mm. Interocclusal 3D distance distortion, new articulators dRM=21.5 ±49.8 mm; predoctoral dental students=68.6 ±64.9 mm, 2D distance distortions, predoctoral dental students articulators dxM =−17.9 ±43.4 mm, prosthodontic residents= −61.9 ±48.3 mm to 69.3 ±115.1 mm. New articulators: The mean dyM= 18.1 ±59.4 mm to 69.3 ±115.1 mm, prosthodontic residents; mean dzM=29.5 ±20.2 mm to 70.1 ±37.8 mm, New articulators: Mean dqM= −0.018 ±0.289 degree, prosthodontic residents= 0.141 ±0.267 degree	NA	Did not fulfil the manufacturer's claim	Neither new nor used articulators met the manufacturer's claimed accuracy of 10 mm in the vertical dimension. Within a year of use, none of the test groups met the criteria for interchangeability, even with the more lenient threshold of 166 mm.	Findings may not be applicable to other systems.

MI, Maximal intercuspation; CAD, Computer Aided Design; IO, Intercuspal Occlusion; CT, Computed tomography; AMG, Average Mounting Group; SFG, Smartphone Facial Scan; PFG, Professional Facial Scan; CBCT, Cone-Beam Computed Tomography; KFG, Kinematic Facebow Group; CAM, Computer Aided manufacturing; NA, Not Available; TMJ, Temporomandibular Joint.

Moreover, caution was advised when employing a Cartesian coordinate system and OrthoCAD™ software in a clinical setting,^30,31 while further study was suggested for the validation of the Panadent virtual articulator and Simplant O and O®.^41,43 Meanwhile, Wong et al³² highlight the fully automatic nature of the MATLAB program (a three-stage algorithm approach) with no manual data extraction required. Similarly, Chou et al³ found CT feasible for various clinical applications, and the capability of CAD/CAM systems was also validated to provide guidance.³⁵ However, Lee et al³⁷ observed that an Artex CR semi-adjustable articulator system is needed to fulfill the manufacturer's claim (Table 3).

GRADE emphasizes strengths and limitations in important areas. Serous concern was observed in methodological limitations as most of the studies had high and medium RoB. Meanwhile, in the remaining domains, no concern was observed. Despite of no concern in all domains except methodological limitation, the level of evidence is considered as low (Table 4).

Table 4.

GRADE certainty of evidence.

GRADE domain	Judgment	Concerns	Level of evidence
Limitations in methodology (risk assessment)	Overall, most of the studies had high and moderate risk of bias	Serous concern	ƟƟ (Low)
Indirectness	Patients, interventions, and comparators in studies provide direct evidence of existing medical questions	No concern
Imprecision	Included studies performed proper statistical analysis	No concern
Inconsistency	No inconsistency was observed	No concern
Publication bias	Even, meta-analysis was not performed due to low quality of studies. However, both positive and negative outcomes (either statistically significant or non-significant) were published	No concern

Eight in vitro studies resulted in a medium risk of bias, with scores ranging from 50% to 70% and concern was raised in different items, including sample size calculation, randomization, blinding and outcome assessor details. Meanwhile, high risk of bias was also observed four studies^3,30,33,42 (Table 5).

Table 5.

Quality assessment for in vitro/lab studies.

Study Reference	Items
	Aim/objectives	Comparison group	Sample size calculation	Methodology explanation	Operator details	Randomization	Methods for outcome measurements	Outcomes assessor details	Blinding	Statistical analysis	Presentation of results	Total	%age	Status
30	2	0	0	2	0	0	2	0	0	2	2	10	45.45	H
40	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
38	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
42	2	0	0	2	0	0	2	0	0	2	2	10	45.45	H
31	2	2	0	2	2	0	2	0	0	2	2	14	63.63	M
16	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
33	2	0	0	2	0	0	2	0	0	2	2	10	45.45	H
41	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
44	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
3	2	2	0	2	0	0	2	0	0	0	0	8	36.36	H
35	2	2	0	2	0	0	2	0	0	2	2	12	54.54	M
37	2	2	0	2	0	2	2	0	0	2	2	14	63.63	M

Abbreviations: H=High RoB, M=Medium RoB

Non-in vitro studies, encompassing clinical trials and cross-sectional/prospective studies, demonstrated high quality (score ≥ 3) in domains 3.1 to 3.5, except domains 3.1 and 3.4 for clinical trials. Cross-sectional studies exhibited good quality in domains 3.2, 3.3, and 3.5, while prospective studies demonstrated good quality across all domains, excluding domain 3.4 (Table 6).

Table 6.

Non-in vitro studies quality assessment.

Study Reference	Study design	Item					Score
		3.1	3.2	3.3	3.4	3.5
39	Controlled Clinical Trail	Can't tell	Y	Y	N	Y	3
34	Controlled Clinical Trail	Can't tell	Y	Y	N	Y	3
36	Controlled Clinical Trail	Can't tell	Y	Y	N	Y	3
43	Cross-sectional	N	Y	Y	N	Y	3
32	Prospective	Y	Y	Y	N	Y	4

Y, yes; N, no.

3.1: Are the participants representative of the target population? 3.2: Are measurements appropriate regarding both the outcome and intervention (or exposure)? 3.3: Are there complete outcome data? 3.4: Are the confounders accounted for in the design and analysis? 3.5: During the study period, is the intervention administered (or exposure occurred) as intended?

Discussion

In the ever-evolving landscape of digital dentistry, the utilization of virtual articulators has garnered increased attention because of their potential to revolutionize diagnostic and treatment planning processes.⁵ This study aims to delve into the findings of comparative analysis, exploring the nuances of accuracy in virtual articulation, the user-friendliness of different software platforms, and the practical implications of these technologies in clinical settings. To make informed choices and advance digital techniques in dental treatment, it is vital to have a full grasp of the strengths, limitations, and comparative benefits of virtual articulators, which have become key instruments in current dental practices.

In the present study, different types of virtual articulator systems were identified, including Panadent, OrthoCAD™, CT, CAD/CAM, PAN 300, and MATLAB programs, and compared to traditional/conventional articulators. Questions can arise as to why virtual articulators are needed, and the possible explanation can be that utilizing virtual reality in prosthetic and restorative dentistry overcomes the constraints of traditional mechanical articulators. It simulates authentic patient data, enabling detailed analyses of static and dynamic occlusions and jaw relations. This advancement addresses the limitations of conventional articulators, providing a more comprehensive and dynamic approach to dental procedures.¹⁷ Meanwhile, before selecting any platform, different attributes such as facebow, intercondylar distance, incisal guide table, condylar inclination, reference plane, lateral condylar inclination, immediate mandibular translation, and capability to validate a centric relationship record should be considered.⁴ As in the present study, every study used different types of software/platform/system/programs; therefore, it is not easy to draw clear and concise conclusions. However, virtual articulators were found to be comparable with traditionally made articulators because virtual articulators offer advantages over traditional counterparts owing to their enhanced precision.¹⁵ Unlike conventional articulators, which rely on physical models and manual adjustments, virtual articulators operate in a digital environment, allowing for greater accuracy in reproducing dental occlusion. They provide dynamic simulations, enabling dentists to visualize and assess jaw movements and occlusal relationships in real-time. In addition, virtual articulators often integrate advanced software features that facilitate comprehensive analysis, such as verifying centric relationship records, assessing intercondylar distances, and simulating different treatment scenarios. Our findings that virtual articulators are accurate and comparable with traditional articulators are in line with another study, which revealed an average deviation of 0.069 mm from the virtual occlusion procedure, with a mean standard deviation of 0.011 mm across all points on the occlusal surface. The primary inference drawn from this investigation is that the precision offered by a virtual occlusion procedure surpasses that achieved through a conventional physical interocclusal record.⁷ Additionally, a scoping review revealed that 19 articles among the included studies reported positive outcomes regarding the described methods of registering and transferring anatomic references to the virtual environment. In contrast, one study reported a negative result for the employed technique.¹¹ As in our study, one platform/system, the Artex CR semi-adjustable articulator system, was not up to mark with the manufacturers' specifications (Table 3). This is in line with the findings of other studies that various Artex articulator models have shortcomings in transferring information obtained from a mounted articulator using magnetic mounting plates.^9,10 Utilizing a virtual articulator offers a potential solution to this issue, as it electronically preserves the position of the dental model in 3D space. This electronic preservation may alleviate the challenges of transferring information from one articulator to another. Meanwhile, in vitro, investigations have demonstrated variations in the accuracy and precision of different mechanical articulator systems.¹⁴

Currently, virtual articulator software/platforms/systems are also efficient and easy to use. Our findings are in line with those of other studies.^6,8 In contrast to the traditional approach, these novel methods operate entirely in an automated fashion. Data extraction for the occlusal surface is automatic, eliminating the need for manual extraction. In addition, tooth landmarks beyond those conventionally employed in surgical planning are automatically extracted. The articulation process for a pair of dental models can be completed in less time.³² Overall, the virtual articulator enhances the dental prosthesis design process in dentistry by incorporating kinematic analysis into CAD systems and Reverse Engineering tools. This introduces significant adaptability for adjusting patient settings, surpassing the limitations of certain mechanical articulators that may lack certain adjustable features. The virtual articulator facilitates the creation of prostheses with heightened accuracy compared to those produced using traditional mechanical articulators. The digitally mounted virtual models of casts enable the diagnosis and treatment planning of prosthetic restorations, ranging from single to multiple crowns and bridges, even encompassing complex cases such as full-mouth rehabilitation, all achieved seamlessly through CAD/CAM systems.¹³ Meanwhile, clinical usability is still in question as caution and further validation studies are needed (Table 3) because additional validation studies are crucial to thoroughly assess the efficacy, safety, and overall performance in real-world clinical settings, as most of the studies were laboratory-based. Further validation studies will help identify potential limitations, address unforeseen challenges, and validate the reliability of the technology across diverse patient populations.

Numerous limitations are evident in this study, primarily stemming from the absence of a singularly focused examination of a specific software, platform, or system and the inclusion of in vitro studies. This can be attributed to the scarcity of available studies. Another contributing factor may be the vast array of virtual articulator software platforms/systems that are currently accessible in the field. In addition, some important parameters like user learning curves, integration challenges, and ergonomic factors were missed, which may be due to the unavailability of data from included studies. Comparative user-friendliness and clinical usability were not explained in detail owing to the unavailability of relevant literature. Future longitudinal studies should develop and adopt standardized protocols for the assessment of accuracy and usability of virtual articulators. Furthermore, an economic evaluation should be performed for the comparison of virtual and physical articulators. Association between different disciplines like, software developers, clinicians, and researchers should also be explored.

Conclusions

This study provides a comprehensive comparison of virtual articulator software, focusing on performance metrics such as accuracy, user-friendliness, and clinical applicability. The variability in the performance was observed and showed a range of precision and ease of use, with some platforms, including Cartesian coordinate system, Panadent virtual articulator, CAD-system, Ortho CAD™, CT, CAD/CAM, PAN 300, and MATLAB program excelling in accuracy and ease of use. Clinical applicability depends on adaptability to patient settings and seamless integration into dental workflows. Overall, virtual articulators generally demonstrate accuracy and precision comparable to traditional counterparts. This systematic review offers practical guidelines for future research to standardize assessment methods and explore the long-term clinical impact of virtual articulators. In addition, an interdisciplinary approach should be used involving different disciplines like software developers, clinicians, and researchers for better comparison and outcomes.

Availability of data and materials

The data presented in this study will be available on request from the corresponding author.

Authors contribution

Ravinder S Saini: Conceptualization, Methodology, Software, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Funding acquisition. Hatim Hashim Alshoail: Investigation, Data Curation, Writing - Original Draft. Masroor Ahmed Kanji: Conceptualization, Methodology, Software, Formal analysis, Investigation, Data Curation, Writing - Original Draft. Sunil Kumar Vaddamanu: Investigation, Data Curation, Writing - Original Draft. Seyed Ali Mosaddad: Validation, Resources, Writing - Review & Editing, Visualization, Supervision. Artak Heboyan: Validation, Resources, Writing - Review & Editing, Supervision, Project administration.

Conflict of interest

None disclosed.