3
THE REPRODUCIBILITY OF CENTRIC RELATION:
This study addresses the repro-
ducibility of the centric relation,
or CR, position. Using bimanual
manipulation, several dentists
were randomly assigned to one
of five patients to clinically de-
termine CR and record this posi-
tion by using the same wax
recording technique. These bite
records, which were then ana-
lyzed by using the Denar Centri-
Check marking system
(Teledyne Water-Pik), were
found to capture condylar posi-
tions with a maximum variation
of 0.1 millimeter, as measured
within the tolerances of the
Denar Centri-Check.
A CLINICAL APPROACH
GREGORY J. TARANTOLA, D.D.S.; IRWIN M. BECKER, D.D.S.; HENRY
GREMILLION, D.D.S.
0ne of the definitions of centric relation, or CR, according to The
Glossary of Prosthodontic Terms, is "maxilla to mandible relation-
ship in which the condyles and disks are thought to be in the mid-
most, uppermost position. It is a clinically determined relationship
of the mandible to the maxilla when the condyle-disk assemblies
are positioned in their most superior position in the mandibular
fossa and against the slope of the articular eminence."' This clini-
cally determined position has also been described as repeatable and
reproducible; therefore, it is a repeatable reference point for dental
therapy.
Several articles address this reproducibility.211 Some of this evi-
dence points to small variations in condylar positions with various
CR methods. For example, Tripodakis and colleagues2 reported that
CR recorded after therapy with bite splints was 0.2 millimeter pos-
terior to an initial CR recording. However, the initial recording may
have used a technique that did not verify the most superior posi-
tioning of the condyle because the condyle cannot move posteriorly
along the anterior slope of the eminence without moving superiorly.
The first recording may have been affected by muscle activity that
positioned the condyle forward. A CR positioning technique should
be able to recognize this forward positioning to be valid and repro-
ducible. Piehslinger and colleagues7 reported a 0.2-mm variation in
CR position when it was measured directly from the patient with
computerized axiography.
Some evidence also suggests that the CR position can vary at dif-
ferent times throughout the day. Latta"' reported that edentulous
patients showed differences in condylar position that were as great
as 2.63 mm at different times during the day. Shafagh, Yoder and
Thayer"' reported that when the position of the condyle in terms of
CR for dentulous patients was evaluated in the morning and again
at night, there were differences. Again, the recorded condylar posi-
tion may not have been the most superior position owing to muscle
activity. Hobo and Iwata' reported only 0.04-mm variation with bi-
lateral manipulation; however, an electronic mandibular recording
microcomputer measured CR position directly from the patient-
not by using methods that are clinically applicable. Kantor,
Silverman and Garfinkel9 reported a variation of 0.13 mm with bi-
lateral manipulation when CR was measured indirectly with a wax
JADA, Vol. 128, September 1997 1245
BESEARCH-
Figure 1. Diagram of predrilled condylar ball/shaft
and stylus.
jaw relation record analyzed
with a toolmaker's mechanical
microscope. However, Kantor
and colleagues measured only
in the anterior-posterior and
coronal planes, not in the supe-
rior-inferior planes. If indeed
this "clinically determined rela-
tionship" as defined in The
Glossary of Prosthetic Terms
shows sufficient variation for
any reason, it cannot be a re-
peatable, reliable reference
point for dental therapy.
The clinical implications of a
variation in CR position can be
significant at the occlusal inter-
face. We have found CR to be a
consistently repeatable position
with very little, if any, varia-
tion. This difference in opinion
may be due to the clinical
method of determining and ver-
ifying the most superior posi-
tion of the condyle in the fossa
and the clinical method for
recording the maxilla-to-
mandible relationship and
transferring to diagnostic casts
rather than due to a lack of
anatomical consistency capable
of reproducing the condylar po-
sition. In other words, we be-
lieve that a clinical method
should verifiably position the
condyle-disk assemblies in their
1246 JADA, Vol. 128, September 1997
Figure 2. Lateral view showing the position of the
dentist's thumbs and fingers when using the biman-
ual manipulation technique.
most superior position within
the fossa. Also, a clinical inter-
occlusal record method should
precisely capture the maxilla-
to-mandible relationship when
the condyles are in their most
superior position; this should
result in a condylar position
that is repeatable and shows
very little, if any, variation.
This study used a straight-
forward clinical method for
recording jaw relationships
when the condyles are in the
most superior position. These
jaw relation records were ana-
lyzed in the superior-inferior
and anterior-posterior planes
with clinically available instru-
mentation.
MAVATERIALS AND
MIETHODS
This study involved 39 mem-
bers of the visiting faculty of
The Pankey Institute for
Advanced Dental Education in
Key Biscayne, Fla. Each faculty
member was randomly assigned
to one of five patients who
served as subjects. All five pa-
tients reported that they had no
history of temporomandibular
joint, or TMJ, pain or related
dysfunction. An examination re-
vealed that each of the five pa-
tients had a normal range and
path of motion. There was no
tenderness in response to palpa-
tion of either the lateral or pos-
terior-lateral aspects of the
joints. Auscultation revealed no
crepitation during rotational
movement. Superior load test-
ing revealed no tension or ten-
derness in the TMJs of any of
the five patients. Before the
study, diagnostic casts had been
fabricated for all five patients.
The maxillary cast was at-
tached to a Denar Ana-Mark
(Teledyne Water-Pik) articula-
tor by means of a Denar
Slidematic (Teledyne Water-
Pik) face-bow. The mandibular
cast was attached to the articu-
lator with a jaw relation record
described in this study.
During the study, each den-
tist recorded CR for his or her
assigned patient using the bi-
manual CR manipulation and
recording techniques taught at
The Pankey Institute. Each
dentist then analyzed these
records using the Denar Centri-
Check (Teledyne Water-Pik) to
compare the condylar positions
captured by each of these jaw
relation records. When this sys-
tem is used, the mandibular
cast remains in the articulator

Figure 3. A properly adapted wax platform has good
retention and stability on the maxillary arch. Note the
slight extension over the facial surface of the cus-
pids and the lack of overlap over the buccal surfaces
of the posterior teeth.
while the upper cast is attached
to the Denar Centri-Check. The
condylar balls are predrilled
from the medial aspect to the
lateral aspect so that the hole is
centered. This hole will receive
a stylus. The upper Denar
Centri-Check member contains
a graphed marking plate rather
than a fossa. The stylus records
the condylar position captured
by a jaw relation record by posi-
tioning the marker through the
hole until the needle tip punc-
tures a hole in the graphed
plate (Figure 1). The stylus,
which has a diameter of 0.6
mm, fits the drilled hole of the
condylar ball with a 0.05-mm
tolerance. A number of records
can be analyzed and the various
positions in the superior-inferi-
or and anterior-posterior planes
can be compared. The diameter
of the hole punctured into the
recording plate was measured
with a Boley gauge.
Examination using the bi-
manual manipulation tech-
nique. All of the dentists in
this study had been trained in
the bimanual manipulation
technique used to position the
condyles to the most superior
position within the fossa, and a
review session had been con-
Figure 4. The lower cuspids and molars
wax on the manipulated
sure simultaneously.
ducted immediately before the
study. The technique involves
having the patient recline in the
dental chair with a slight bend
to the torso and with the feet el-
evated slightly higher than the
head. The dentist's chair is ad-
justed so that the dentist's
thighs are approximately paral-
lel to the floor. The patient's
chair is adjusted so that the
dentist can comfortably grasp
and easily rotate the mandible
with his or her hands.
The dentist's last finger is
placed at the angle of the pa-
tient's mandible, while the rest
of the fingers are together, with
the pads of the fingertips on the
inferior border of the mandible.
The tips of the thumbs are
placed on the chin button with a
conscious effort made to elimi-
nate any pressure that would
cause distal movement. The pa-
tient's cranium is stabilized ei-
ther against the dentist's ab-
domen, if the dentist is
operating directly behind the
patient, or between the dentist's
forearm and rib cage, if the den-
tist is operating at the patient's
side (Figure 2). The patient is
instructed to open and close his
or her mandible without guid-
ance or restriction. When a re-
RESEARCH
engage the
centric relation arc of clo-
peatable arc is observed, the
dentist can begin to duplicate
this hinging movement using
his or her hands. The dentist
applies gentle upward pressure
with the last two fingers of both
hands to seat the condyles in
their most superior position.
Several articles addressing
the load-bearing nature of the
TMJs state that the anatomy of
the TMJs is designed to accept
loading.'2-16 In fact, the TMJs
are always subjected to some
degree of load (even during vo-
calization, for example) and, in
fact, are never without a load,
even when a patient is wearing
bite splints.
Because the TMJs are de-
signed to accept loads, our ex-
amination should have tested
the load-bearing capability of
the patients' TMJs. The load-
bearing capacity of the TMJs
can be tested (that is, com-
pressed)"7 to help the dentist de-
termine if the condyles are in
the most superior position and
are not being held forward by
muscle. This test, which can be
accomplished by using the bi-
manual manipulation technique
described earlier, involves ap-
plying upward torquing force
with the last two fingers while
JADA, Vol. 128, September 1997 1247
BES[ARCH-
Figure 0. A lack Ot buccal overlap Ot posterior teeth
allows verification of a precise fit on the cast.
the thumbs brace their position
on the chin. This torquing force
should be applied in three in-
creasing increments of gentle,
moderate and firm force, with
the absence of any pain, tension
or tenderness confirmed by the
patient after each increment.
The absence of pain, tension or
tenderness through all three in-
crements of this load testing
confirms that the TMJ struc-
tures can accept loading and
that the condyle is not postured
forward by muscle. However,
the fact that there is no pain,
tension or tenderness does not
necessarily confirm that the
disk or other intracapsular
structures are either in a nor-
mal condition or position. This
is the result of an adaptive pro-
cess that still allows full superi-
or seating and superior com-
pression of these structures
without tension or tenderness.
On the other hand, the pres-
ence of pain, tension or tender-
ness can be due to either muscle
activity or hyperactivity in-
duced by occlusal interfer-
ences-in particular, the lateral
pterygoid,'8 inflammation in the
retrodiskal tissues, an anterior-
ly displaced disk that results in
the condyle's compressing
retrodiskal tissues, perforated
tissues or distal displacement
1248 JADA, Vol. 128, September 1997
Figure 6. Assembly of casts on Denar Centri-Check
(Teledyne Water-Pik) and use of the stylus.
caused by the dentist. Any of
these factors can prevent a pre-
dictably repeatable seating of
the condyle in the most superior
position, and this may account
for some of the variation report-
ed in other studies.
Other aspects of a compre-
hensive examination-in partic-
ular, palpation, auscultation
and range of motion-will yield
the information the dentist
needs to make a specific diagno-
sis regarding the structure of
each TMJ. Once the examina-
tion is complete, the dentist can
fabricate a jaw relation record.
If, however, superior compres-
sion reveals tension or tender-
ness or if other aspects of the
examination reveal some intra-
capsular disorders, this jaw re-
lation record cannot be consid-
ered to reflect CR. Rather, it
would be a tentative or treat-
ment record from which oc-
clusal therapy could begin. Any
of these conditions, if uncovered
during an examination, could
prevent complete superior seat-
ing of the condyles within the
fossa and could therefore com-
promise the repeatability of this
position. Therefore, the dentist
must determine this first by
performing a comprehensive ex-
amination. All of the patients in
this study underwent the com-
prehensive examination de-
scribed earlier, and it was de-
termined that all of the pa-
tients' TMJs could be seated in
their most superior position and
that none of the patients had
tension or tenderness when
their TMJs were compressed in
a superior direction.
The jaw relation record-
ing technique. All of the den-
tists in the study had been
trained to use a jaw relation
recording technique currently
taught at The Pankey Institute.
They also were given a review
session immediately before par-
ticipating in this study.
This technique involves
adapting two layers of a rigid
wax platform to the maxillary
arch either directly or on a study
cast extending from the mesial
aspect of the cuspids to the last
molars; at the same time, the
dentist comfirms that there is no
contact with soft tissue. The buc-
cal borders should be trimmed
halfway between the central
fossa and the buccal cusp tips.
This allows the dentist to verify
that there is precise contact be-
tween the wax and the teeth
clinically as well as on the study
cast (Figure 3). A slight exten-
sion folded over the facial sur-
faces of the cuspids will enhance
retention of the platform.

*Denar Centri-Check marking system (Teledyne Water-Pik).
[Aw
While this trimmed platform
is soft, it is aligned on the max-
illary arch and the mandible is
closed into the wax until the
lower cuspids engage the plat-
form, thereby adapting the plat-
form to the maxillary arch. This
wax platform is cooled with
compressed air while the teeth
are together, thereby control-
ling distortion of the wax dur-
ing this cooling process. A melt-
ed rigid wax is applied to the
indentations of the lower cus-
pids, and the dentist carefully
manipulates the mandible with
two hands, following all the pre-
viously described steps, until
the lower cuspid tip engages
this wax.
The wax is cooled while con-
tact with the cuspids is main-
tained and while the dentist
verifies that both cuspids touch
simultaneously and with equal
intensity on this manipulated
CR arc of closure. Once this has
been confirmed, the dentist ap-
plies melted rigid wax to a right
and a left molar cusp tip inden-
tation on the platform. Once
again, the dentist carefully ma-
nipulates the mandible and
closes it on the CR arc of closure
until the lower cuspids engage
the cuspid wax indentation,
thereby recording a molar cusp
M,].
e.A.r6N. wh.. I];.,
tip on each side of the arch
(Figure 4). This wax is then
cooled while the four teeth are
making contact and the dentist
confirms that the contact is of
simultaneous and equal intensi-
ty. The dentist then verifies the
fit of the record on the cast
(Figure 5).
Each of the records in this
study was analyzed with the
Denar Centri-Check. The first
bite record was positioned be-
tween the maxillary and man-
dibular cast and was stabilized
with downward hand pressure
on the upper member of the
marking system. The stylus was
positioned medially with only
enough pressure to puncture a
hole, which was the diameter of
the stylus tip, in the recording
plate (Figure 6). Using the same
recording plate, the dentist ana-
lyzed the subsequent bite
records in an identical fashion.
If a subsequent bite record had
caused the stylus to capture the
same position as the previous
record, the marker should have
fit precisely within the previous
puncture mark without increas-
ing the diameter of the first
mark. If all of the bite records
for a patient result in a precise
positioning of the stylus into the
hole punctured by the first
RESEAR CHimi
.' `
.,*m 4i- "., yl ri-.. .., ..
Aku I-,. 21k-,
..- .,;- .,., -.X.j
record, the diameters of the
holes created by all bite records
should be the same as the diam-
eter of the hole created by the
first record. On the other hand,
if the needle-point recordings
that form the subsequent bite
records do not position them-
selves precisely into the hole
created by the first bite record,
the diameter of the hole created
by these subsequent records
would be greater than the diam-
eter of the hole created by the
first record.
RESULTS
The recording graphs shown in
Figure 7 are representative of
the graphs for all five patients
in the study. The diameter of
the hole punctured by one
record is 0.6 mm. The table
shows the diameters of the
holes created by the various
records of both right and left
TMJs for each of the five pa-
tients. Both the anterior-poste-
rior and superior-inferior di-
mensions of the holes were
measured. Two bite records for
Patient No. 3 captured condylar
positions that were displaced
from the others by several mil-
limeters. This was due to an in-
stability of the wax record on
the maxillary cast, resulting
JADA, Vol. 128, September 1997 1249
-RESEAARCH
Figure 7. Denar Centri-Check recording plates showing condylar position captured by bite records for two pa
tients. A. Graph for Patient No. 1. B. Graph for Patient No. 3 shows the outliers as a result of an unstable record.
from contact with soft tissue.
The two dentists who made
those bite records made new ones,
which captured a condylar posi-
tion coincident with the others.
DISCUSSION
This study has shown that
many dentists using the clinical
manipulation and recording
techniques described in this
study can achieve repeatable
CR measurements with a maxi-
mum variation of 0.1 mm, as
measured by the Denar Centri-
Check. This degree of precision
in reproducing CR measure-
ments suggests a precise fit of
the condyle within the fossa. It
appears to us that this degree of
precision would not be possible
if the osseous components of the
condyle and fossa were not
braced. If the joint was braced
not by the osseous components
but, rather, by soft-tissue com-
ponents such as muscle or con-
nective tissue, we would have
expected more variation in the
condylar positions recorded by
the different dentists. Also, if
soft tissues, such as retrodiskal
tissue resulting from an anteri-
orly displaced disk, were resist-
ing the upward force during the
superior compression test'4
rather than osseous and fibro-
cartilage tissue, we would have
1250 JADA, Vol. 128, September 1997
expected the patients to report
discomfort.
The precision of the repro-
duced CR jaw relation records
also suggests to us that the
shape of the osseous compo-
nents of the condyle and fossa
can be a factor that facilitates
this repeatability. It appears
that when the mandible is being
rotated with the condyles in CR,
it is the superior surface of the
condyle fitting against an inferi-
or surface of the fossa, rather
than the anterior surface of the
condyle being braced on the
slope of the eminence, that fa-
cilitates repeatability. The de-
gree of repeatability demon-
strated by this study would
appear to be impossible if the
condyle was braced against a
slope without a definite superi-
or osseous stop. A CR technique
that verifiably positions the
condyle to the superior limit of
this osseous brace is important
in achieving this repeatability.
Other CR techniques, such as
using leaf gauges or anterior
bite stops, are described in the
literature and could provide the
basis for another similar study.
The precision of the interoc-
clusal recording technique is
also important for this CR re-
peatability. Care must be exer-
cised to ensure an accurate fit
of all the components of the in-
terocclusal record both in the
patient's mouth and on an accu-
rate set of diagnostic casts.
Other interocclusal recording
techniques that have been de-
scribed in the literature, such
as the use of silicone putties,
could also be the subject of fu-
ture studies. Studies that have
reported more variation in the
CR position may have used
techniques that did not position
the condyle to the more repeat-
able osseous brace. Techniques
that incorporate any vector of
force directed distally rather
than superiorly can push the
condyle down the posterior wall
of the fossa, or they can trigger
patients to resist. This could
cause the lateral pterygoid to
pull the condyle down and for-
ward along the eminence. A su-
perior compression test that re-
sults in no report of tension or
tenderness is an important step
in verifying that the condyles
are in the most superior posi-
tion and are not held forward by
muscle. Another reason for the
variability found with other
techniques could be that the CR
recording technique used in
other studies made a precise fit
of all the components difficult.
We found that any soft-tissue
contact with the record made
 E
[SEARC H

precise fitting of the record on must be followed carefully. The 6. Alexander SR, Moore RN, Dubois LM.
Mandibular condyle position: comparison of
the cast very difficult. various steps involved in fabri- articulator mountings and magnetic reso-
cating the CR record must also nance imaging. Am J Orthod Dentofacial
CONCLUSIONS Orthop 1993;104(3):230-9.
be carefully followed and con- 7. Piehslinger E, Celar A, Celar R, Jager W,
This study has shown that an firmed. This study proposes Slavicek R. Reproducibility of the condylar ref-
erence position. J Orofacial Pain 1993;7(1):68-
indirect method of recording CR that CR can become a pre- 75.
produced results as accurate as dictable, repeatable starting 8. Hobo S, Iwata T. Reproducibility of
mandibular centricity in three dimensions. J
those reported directly from pa- point for occlusal therapy. It Prosthet Dent 1985;53(5):649-54.
tients in whom computerized should also be considered as a 9. Kantor ME, Silverman SI, Garfinkel L.
Centric relation recording techniques-a com-
techniques were used. It has starting point for various re- parative investigation. J Prosthet Dent
also shown that CR records that search projects that correlate 1972;28(6):593-600.
10. Latta GH Jr. Influence of circadian peri-
capture condylar positions with the relationship between occlu- odicity on reproducibility of centric relation
a maximum variation of 0.1 mm, sion and various temporo- records for edentulous patients. J Prosthet
Dent 1992;68(5):780-3.
as measured by the Denar mandibular disorders. . 11. Shafagh I, Yoder JL, Thayer KE.
Centri-Check, can be made by a Diurnal variance of centric relation position. J
Prosthet Dent 1975;34(5):574-82.
number of dentists for the same 1. The Academy of Prosthodontics. The glos- 12. Hylander WL, Bays RA. Experimental
patient. We have also suggested sary of prosthodontic terms. 6th ed. St. Louis: analysis of temporomandibular joint relation
Mosby; 1994. force in macaques. Am J Phys Anthropol
an anatomic basis for this re- 2. Tripodakis AP, Smulow JB, Mehta NR, 1979;51(3):433-56.
producibility. Clark RE. Clinical study of location and repro- 13. Hylander WL. An in vivo strain gauge
ducibility of three mandibular positions in re- analysis of the squamosal-dentary joint reac-
The technique of manipulat- lation to body posture and muscle function. J tion force during mastication and incisal bit-
ing the mandible to position the Prosthet Dent 1995;73(2):190-8. ing in Macaca mulatta and Macaca fascicu-
3. Rinchuse DJ. A three-dimensional com- laris. Arch Oral Biol 1979;24(9):689-97.
condyles to CR parison of condylar change between centric re- 14. Boyd RL, Gibbs CH, Mahan PE,
and verifying lation and centric occlusion using the Richmond AF, Laskin JL. Temporo-
mandibular position indicator. Am J Orthod mandibular joint forces measured at the
the most supe- Dentofacial Orthop 1995;107(3):319-28. condyle of the Macaca arctoides. Am J Orthod
rior position 4. Utt TW, Meyers CE Jr., Wierzba TF, Dentofacial Orthop 1990;97(6):472-9.
Hondrum SO. A three-dimensional compari- 15. Hekneby M. The load of the temporo-
son of condylar position changes between cen- mandibular joint: physical calculations and
tric relation and cen- analysis. J Prosthet Dent 1974;31(3):303-12.
tric occlusion using 16. Ito T, Gibbs C, Marguelles-Bonnet R, et
w _ the mandibular posi- al. Loading on the temporomandibular joints
Dr. Tarantola Is tion indicator. Am J with five occlusal conditions. J Prosthet Dent
clinical director, Orthod Dentofacial 1986;56(4):478-84.
Department of Orthop 1995;107(3): 17. Lobbezoo-Scholte AM, Steenks MH,
Education, The
298-308. Faber JA, Bosman F. Diagnostic value of or-
5. Parlett K, thopedic tests in patients with temporo-
Pankey Institute for
Paesani D, Tallents mandibular disorders. J Dent Res
Advanced Dental Dr. Becker Is chair- RH, Hatala MA.
Educatlon, 240 man, Department of Dr. Oremililon is di= Temporomandibular
1993;72(10):1443-53.
18. Mahan PE, Wilkinson TM, Gibbs CH,
Crandon Blvd., Key Education, The rector, Facial Pain joint axiography and Mauderli A, Brannon L. Superior and inferior
Biscayne, Fla. Pankey Institute for Center, University MRI findings: a com- bellies of the lateral pterygoid muscle EMG
33149. Address Advanced Dental of Florida, College parative study. J activity at basic jaw positions. J Prosthet Dent
reprint requests to Education, Key of Dentistry, Prosthet Dent 1983;50(5):710-8.
Dr. Tarantola. Biscayne, Fla. Gainesville. 1993;70(6):521-31.

JADA, Vol. 128, September 1997 1251