Journal of Oral Rehabilitation 2001 28; 55–63
Review
An appraisal of the literature on centric relation. Part III
A. KESHVAD & R. B. WINSTANLEY Department of Restorative Dentistry, School of Clinical Dentistry, University of
Sheffield, Sheffield, U.K.
SUMMARY The literature directly and indirectly re-
lated to centric relation (CR) has been reviewed
chronologically. More than 300 papers and quoted
sections of books have been divided into three sec-
tions. The first two parts are related to CR. Studies
in this group mainly compared, either the position
of the mandibular condyle or the mandible itself in
different CR recordings. Various tools were discussed
for this purpose. The third part of the paper is about
CR–centric occlusion (CO) discrepancy. CR still re-
mains one of the controversial issues in
Part III: The discrepancy between centric
relation and centric occlusion
Centric occlusion (CO) has always been a tooth to tooth
position. Maximum intercuspation (MI) and intercuspal
position (ICP) have been used synonymously. Recently,
the Glossary of Prosthodontic Terms (1994) has added
to the confusion by defining CO as a jaw position when
the mandible is in centric relation (CR) and the teeth are
in MI. This situation was formerly described as centric
relation occlusion.
Numerous studies have reported that the majority of
patients with a natural dentition show a discrepancy
between the occlusal position of the mandible in CR and
MI (Posselt, 1952; Hodge & Mahan 1967; Rieder, 1978).
This discrepancy is present in at least 90% of dentitions,
and Posselt (1952) indicated that the antero-posterior
distance between the retruded (now CR) and the ICP
position was about 1·25-mm (9 1·00) on average. This
discrepancy was found to remain constant even follow-
ing successful orthodontic treatment. In children, the
distance was smaller (0·85 90·6 mm).
© 2001 Blackwell Science Ltd
prosthodontics and orthodontics. Debates such as
mounting casts on the articulator by reproducible
records for orthodontic treatment planning and
end results, and whether or not orthodontic treat-
ment based on CO causes TMJ dysfunction, remain
unsolved. The references are listed at the end of
Part III.
KEYWORDS: articulators, centric occlusion, centric
relation, intercuspation, TMJ dysfunction
Clinically, the difference between the two occlusal
positions can easily be determined by closing the
mandible in its CR position by manual guidance until
the first tooth contact is established. This used to be
called retruded contact position (RCP) for many years
and it is now called centric relation contact position
(CRCP). If the patient is then requested to squeeze the
teeth together, usually a protrusive movement, some-
times with a lateral component, will permit the
mandible to slide towards MI. This centric slide is easy
to observe clinically but for a more precise evaluation
of its length and direction, an occlusal analysis on
articulator mounted casts is necessary.
In Posselt’s classical diagram (envelope of motion),
the centric slide is designated from first CR contact
position to MI. When CR and MI coincide, no prema-
ture tooth contact occurs when closing along a termi-
nal hinge movement, with the result that there will be
no slide. In these instances, Posselt’s diagram appears
somewhat modified in the region of MI, where CR and
CO are the same.
55
56 A. KESHVAD & R. B. WINSTANLEY
The significance of the discrepancy is based on the
presence of premature contacts, so that the patient is
only able to find a stable occlusal position during clo-
sure in CR by sliding into MI. Premature tooth contacts
in general, and premature contacts during closing in
CR in particular, might be trigger points for para-func-
tional activities like clenching and bruxism. Such para-
functional activities probably have a far greater
potential for injury than any other purely functional
activity.
Hodge & Mahan (1967) investigated the mandibular
movement between what we call today CR and CO
even though the title of the study was ‘A study of
mandibular movement from CO and MI’. One hundred
and one adults were examined to determine whether
there were any CR– CO slides and, in the presence of a
slide, the extent and direction was measured. It was
found that almost half the subjects did not have either
antero-posterior or vertical mandibular movement
from CR to CO. As for lateral movement, 15 subjects
showed this component of movement.
McNamara & Henry (1974) titled their study ‘Termi-
nal hinge contact in dentitions’, although the aim was
to investigate the number of tooth contacts in CR and
CO. Cephalometric radiography was used to compare
the positional differences between CR and CO qualita-
tively. Electromyography was also used to compare
muscle contraction between the two positions. A posi-
tional difference between CO and CR was demon-
strated in all 15 subjects. However, temporal and
masseter muscle activity during maximal isometric
contraction did not differ significantly at these two
positions.
One of the most often quoted studies in the field of
CR– CO is by Glickman et al. (1974). In this study a
completely reconstructed, natural dentition was stud-
ied under conditions of actual function to determine
which of the two occlusal relationships the patient
used during chewing and swallowing. Multi-frequency
radio transmitters were constructed and inserted into
the pontics of full mouth restorations. Two full mouth
restorations were made for the patient, one in CO and
the other in CR. Telemetric testing with the patient
chewing and swallowing was performed, and the resul-
tant tooth contact patterns were recorded before and
after preparing the restorations. They found that the
prosthesis with intercuspation in CR did not alter the
tendency for tooth contacts to occur in the patient’s
© 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 55–63
CO. The patient had difficulty in achieving MI when
allowed to close freely with the prosthesis designed to
intercuspate in CR. They concluded that the use of the
terminal hinge (the term ‘terminal hinge position’ was
used as a synonym for CR in this study) in oral rehabil-
itation is subject to question since it appears that the
patient would not function in this position. It was
suggested that the use of CR as a reference position is
doubtful because the distance to the existing CO posi-
tion is variable and unpredictable.
Azarbal (1977) compared three occlusal positions:
CR, CO and Myo-monitor positions. Extra-oral
clutches were used to compare the three positions
antero-posteriorly and laterally. The study indicated
that the Myo-monitor position was almost always
anterior and lateral to CR and CO. The author rejected
the use of the Myo-monitor* as a suitable method for
jaw positioning because the method was not capable of
locating the jaw as far posteriorly as possible. Today
such a conclusion based on these findings cannot be
drawn.
Rieder (1978) authored an epidemiological study of
323 adult patients to find the prevalence and amount
of mandibular displacement from retruded contact po-
sition (RCP) (CR) to intercuspal position (IP) (CO).
Direct clinical measurements revealed that 86% of the
subjects had mandibular displacement from CR to CO
in one or more directions of movements. All of the
patients with mandibular displacement demonstrated a
vertical component of movement, nearly all exhibited
an anterior component, and a third showed lateral
movement.
Kleinrok (1986) used a Functionograph (a similar
device to the Gothic arch clutches that were described
earlier) to classify CO disturbances into the following
classes:
1. Class I: CO disturbances without lateral displace-
ment of the IP (CO) and RCP (CR), related to either
a pathological coincidence of the RCP and IP or an
unacceptable sagittal slide in centric which could be
pathologically elongated either anteriorly and/or
posteriorly.
2. Class II: CO disturbances with a lateral displace-
ment of IP related to either a pathological coinci-
dence of RCP and IP, or with a fronto-lateral slide
from a normal or a displaced RCP into IP.
* Whip-Mix Corporation, Louisville, KY, U.S.A.
 AN APPRAISAL OF THE LITERATURE ON CENTRIC RELATION
Rosner & Goldberg (1986) designed a study to inves-
tigate the three-dimensional differences between CR
and CO. A custom made Buhnergraph on a Whip-Mix†
articulator was used to indicate the differences.
Records of 75 patients indicated that 60% of the CO
records were placed anterior and inferior to CR. There
was no CO marking on the posterior superior quadrant
suggesting that CO is unlikely to be posterior and
superior to CR.
Shildkraut et al. (1994) were among the orthodon-
tists who strongly believed that hand held articulated
casts used routinely in orthodontic treatment planning
should be replaced with the so-called prosthodontic
mounting with facebow and CR records. They also
criticized the use of conventional lateral cephalometric
radiographs for orthodontic diagnosis because such ra-
diographs are taken with the patient in CO. They
commented that cephalometric radiographs should be
transferred to CR radiographs and the treatment plan-
ning and tracing of the radiographs be based on the
modified CR radiographs. They designed a study to
determine if there was a significant difference between
24 cephalometric measurements of mandibular posi-
tion derived from a CO tracing compared with those of
a converted CR tracing. They hypothesized that:
providing statistically significant differences exist be-
tween CR and CO, this could affect the diagnosis and
treatment planning necessary to correct the malocclu-
sion. A radiographic conversion method, devised by
Slavicek (1988) was used to modify CO cephalomet-
rics. A SAM‡ articulator and mandibular position indi-
cator was used to indicate the differences in the
models. CR and CO tracings on radiographs were also
compared by computer software. It was found that
mandibular positions were significantly different be-
tween a CO tracing and the same tracing converted to
CR. The condyle was always vertically displaced and
most often positioned distally when the teeth were in
CO. It was concluded that, to avoid errors in diagnosis,
treatment plans should be formulated from lateral
cephalograms that have been converted to CR.
Shildkraut’s paper was strongly criticized by
Rinchuse (1995a) who believed CR and CO are like
apples and oranges and, thus, not comparable. He
wrote ‘In this regard, the Shildkraut et al. article appears to
†
Whip-Mix Corporation, Louisville, KY, U.S.A.
‡
SAM, München, Germany.
© 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 55 – 63
57
be an ill-founded attempt to relate a lot of nonsense to
orthodontic diagnosis’. Shildkraut believed that, assum-
ing CR and CO are different in all patients, this is not
indicative of TMD or any other problem in orthodontic
diagnosis. Rinchuse objected to the idea of CR mount-
ing in orthodontics and believed that gnathology is a
thing of the past that should not be applied to the
principles of orthodontics.
A similar study to Shildkraut was performed by Utt et
al. (1995) but did not include any radiographic assess-
ment. They measured CR–CO discrepancy on 107 pa-
tients and related it to the age, sex, type of occlusion
and ANB angle. Averages of antero-posterior
(0·61 mm), supero-inferior (0·84 mm) and lateral
(0·27 mm) mandibular shifts from CR to CO were
reported. They indicated a weak correlation of magni-
tude and direction of CR–CO differences between right
and left TMJs. They suggested that mounted study casts
should be part of the examination and treatment plan-
ning. No further conclusion was drawn and the study
only indicated that there are differences between CR
and CO, something that they did not need to prove, as
we know that nearly 90% of the normal healthy sub-
jects have such a discrepancy without any problem.
Rinchuse (1995b) had an opposing view again, and
repeated his claim that these two positions are not
comparable and, thus, the basis of the study is flawed.
He summarized his criticism as follows: ‘Because the
study by Dr Utt is descriptive rather than experimental
(longitudinal/prospective) or observational (cross-sectional/
retrospective), it must have a ‘‘sound’’ theoretical basis. I
found the basic premise for this study faulty. Furthermore,
the methodology of this study is tenuous. In addition I am
still not certain what Dr Utt’s study was about. Since he did
not directly define CR and CO, I do not know for sure what
was actually recorded and measured in the study’.
Later, Roth (1995), Williams (1995a,b), Carter
(1995), Chubb (1995), Hew (1996) and Alpern (1996)
defended Utt’s position and emphasized that a require-
ment in orthodontics is the necessity of accurately
mounted study casts. Williams said: ‘There is no way you
can evaluate condylar position and functional occlusion with-
out the use of an articulator. I challenge anyone on a clinical
level to disprove that statement …. The academicians must
get their heads out of the ‘scientific’ clouds and come back to
reality. The fact that one is astute at doing research does not
make one a good clinician. In fact it is usually the opposite.
That is why they are in research.’
58 A. KESHVAD & R. B. WINSTANLEY
The idea of functional orthodontics and the use of
articulators still remains controversial. However, recent
publications in the field of CR have certainly affected
many orthodontists and opened a new era in diagnosis
and treatment planning in this field.
Conclusion
The literature directly and indirectly related to CR has
been reviewed. More than 300 papers and quoted
sections of books have been divided into three sections.
The first two parts were related to CR or mandibular
position of CR. Studies in this group mainly compared
either the position of the mandibular condyle or the
mandible itself in different CR recordings. Various tools
were indicated for this purpose. There is still no evi-
dence in the literature to prove that these positional
differences are at the level of the condyle itself or the
mandible. It is more probable, however, that all posi-
tional differences are related to the mandible not to the
condyle unless the position of the condyle is clearly
illustrated by a three-dimensional diagnostic tool such
as computer tomography scan. Many authorities are
still using the older definition of CR in their teaching or
publications possibly because of out of date informa-
tion or difficulty in adapting their skills to the new
definition. CR still remains one of the controversial
issues in prosthodontics and orthodontics and debates
such as mounting casts on the articulator by repro-
ducible records for orthodontic treatment planning and
end results, and whether or not orthodontic treatment
causes TMJ dysfunction remains unsolved. The follow-
ing can be be concluded from the literature.
“ CR is still the final solution for the reorganized
approach in occlusion although its definition has
changed several times and is expected to change
again.
“ The Glossary of Prosthodontic Terms should be re-
garded as a standard reference in the field of CR to
avoid confusion and diversity in CR particularly in
dental education.
“ Bite force changes the position of the condyles supe-
riorly and sometimes anteriorly.
“ Neuromuscular recordings or the Myo-monitor are
not repeatable and place the condyles more anteri-
orly than CR.
© 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 55–63
“ Bimanual mandibular manipulation is one of the
repeatable and consistent methods of recording CR.
“ Using the words retruded and most posterior, al-
though quoted in the literature, is not acceptable
any more because the posterior portion of the TMJ
is fully innervated and contains posterior attach-
ment of the TMJ disc. TMJ morphology encourages
inferior condylar displacement if the mandible is
pushed backwards.
“ A deprogrammer is necessary for CR records in
dentate subjects.
“ The Gothic arch tracing can be used as a diagnostic
tool for assessing TMJ function in addition to its use
with CR records.
“ Repeatability is a valuable tool in assessing the
validity of a CR record.
“ CR is a border position, but whether or not patients
use it during function (i.e. it is a functional position)
remains controversial.
The third part of the literature concerned CR–CO
discrepancy. It was found that some authors believe
this discrepancy should be eliminated as it is a sign of
disharmony in the occlusion. Others believe that this is
the normal feature of a dentition that nature has pro-
vided as a result of functional vectors of forces and,
thus, should be left alone if there is no sign of dysfunc-
tion in the TMJ. This issue remains controversial in the
literature.
The only possible way of observing the condylar
position of a CR record seems to be opening the TMJ
and looking at it while it is in a specific spatial position,
which is totally impractical, although it can be applied
to cadavers. Radiography is recommended as a solution
to this problem but this method can only assess (in two
dimensions) the position of one joint at a time.
One final point is the difference between the CO
definition from the Glossary of Prosthodontic Terms
(1994) and the CO definition that is used routinely in
dental practice today. The Glossary’s definition looks
confusing because a mandibular position (MP) in
which MI and CR are coincidental was described as
CO. This is the opposite of what has been known for 30
years of CO. CO has always been a tooth to tooth
relation with MI independent of MP. However, the
latest CR definition of the Glossary, although changed
many times, sounds more realistic and applicable in
real practice. The MP that the condyles are in CR and
 AN APPRAISAL OF THE LITERATURE ON CENTRIC RELATION
teeth are maximally intercuspated is recommended to
be called centric relate occlusion or CRO.
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Correspondence: Dr R. B. Winstanley, Department of Restorative
Dentistry, School of Clinical Dentistry, University of Sheffield,
Claremont Crescent, Sheffield, S10 2TA, U.K. E-mail:
r.winstanley@sheffield.ac.uk