CLINICAL RESEARCH

Comparison of the Replicability of

Routinely Used Centric Relation
Registration Techniques
Alireza Keshvad, DDS, PhD,1 and Raymond B. Winstanley, BDS, MDS2

Purpose: This study was conducted to determine statistically the most repeatable mandibular
position of 3 centric relation methods.
Materials and Methods: Three centric relation recording methods commonly reported in the
literature were selected: bimanual mandibular manipulation with a jig, chin point guidance with a jig,
and Gothic arch tracing. Fourteen healthy adult volunteers (7 males and 7 females), with an average
age of 26.61 ⴞ 4.20 years and no history of extractions, temporomandibular joint dysfunction, or
orthodontic treatment, were selected for the study. Accurate casts were mounted on an articulator
(Denar D4A) by means of a facebow and maximum intercuspation silicone registration record. A
mechanical 3-dimensional mandibular position indicator was constructed and mounted on the
articulator enabling the operator to analyze the mandibular positions in 3 spatial axes (x, antero-
posterior; y, superoinferior; z, mediolateral shift). Each centric relation method was recorded four
times on each subject (at baseline, 1 hour, 1 day, and 1 week at approximately the same time of day).
Records were transferred to the articulator, and data were extracted using a stereomicroscope
modified to accept the mandibular position indicator.
Results: Variability within subjects ranged from 0.03 mm (left-side z axis for the bimanual method)
to 1.6 mm (left-side y axis for the Gothic arch method). To indicate the least variable (most
repeatable) method a comparison was made using the F test. The bimanual method was the most
consistent, showing between 10.11 (p ⴝ 1) and 0.438 (p ⴝ 0.005) times less variation than the Gothic arch
method (the least consistent). The repeatability of the chin point guidance method was somewhere
between the other 2 methods.
Conclusions: The results of this study showed that of the 3 centric relation methods evaluated, the bi-
manual manipulation method positioned the condyles in the temporomandibular joint with a more con-
sistent repeatability than the other 2 methods, whereas the Gothic arch was the least consistent method.
J Prosthodont 2003;12:90-101. Copyright © 2003 by The American College of Prosthodontists.

INDEX WORDS: jaw relation, maxillomandibular relations, articulator, Gothic arch tracing,
bimanual mandibular manipulation, chin point guidance, anterior jig, clinical research, human
subject, occlusion, repeatability

V ARIOUS METHODS for assessing the validity

of centric relation records have been sug-
gested. Repeatability still remains 1 of the most
suitable methods for evaluating a mandibular
record to be used for articulator cast mounting,
denture construction, and occlusal equilibration. If
a mandibular record is physiological and provides
comfort for the patient but is not reproducible, then
From the Department of Adult Dental Care, School of Clinical the dentist cannot evaluate treatment outcomes.
Dentistry, University of Sheffield, Sheffield, U.K.
1 Repeatability is 1 of the criteria for accepting a
Visiting Lecturer
2
Reader in Restorative Dentistry centric relation record, and many investigators
Accepted February 13, 2003 have used this method as a review of the literature
Presented as a poster at the American Association for Dental Research demonstrates.
annual meeting, Minneapolis, MN, March 1998
Correspondence to Raymond B. Winstanley, Department of Adult Dental
Care, School of Clinical Dentistry, University of Sheffield, Claremont
Crescent, S10 2TA, Sheffield, U.K. E-mail: r.winstanley@sheffield.ac.uk Review of the Literature
Copyright © 2003 by The American College of Prosthodontists
1059-941X/03/1202-0001$30.00/0 The literature on centric relation is vast, and the
doi: 10.1016/S1059-941X(03)00036-6 definition and methods of attaining centric relation

90 Journal of Prosthodontics, Vol 12, No 2 ( June), 2003: pp 90-101

 June 2003, Volume 12, Number 2
records have always been controversial. Jasinevicius
et al1 found in their study on the definitions of
centric relation taught in 7 U.S. dental schools that
there was no consensus definition. The glossary of
dental terminology published every 6 years by the
Academy of Prosthodontics (formerly known as the
Academy of Denture Prosthetics) has changed the
definition of centric relation often. The 1999 edition
of that publication2 has 7 definitions for centric
relation. The definition used in this article (which
was also the definition in the 5th edition, published
in 1987) is as follows: “The maxillomandibular re-
lationship in which the condyles articulate with the
thinnest avascular portion of their respective disks
with the complex in the anterior-superior position
against the shapes of the articular eminencies. This
position is independent of tooth contact. This posi-
tion is clinically discernible when the mandible is
directed superior and anteriorly. It is restricted to a
purely rotary movement about the transverse hor-
izontal axis.”
Grasso and Sharry3 investigated the duplicability
of arrow-point tracings in dentate subjects, the
objective being to determine whether the position
of the arrow-point apex remained constant over
time. Fifteen subjects made intraoral Gothic arch
tracings at 4 time intervals. The results indicated
that significant changes in apex position occurred
over time. The authors suggested that these results
supported the theory that freedom in centric rela-
tions more nearly approaches the physiologic activ-
ity of the mandible than do occlusions locked pre-
cisely in 1 centric position.
Shafagh and Amirloo4 studied the replicability of
chin point guidance and an anterior programmer
on 20 patients with angle class I occlusions. Six
centric relation records were made for each patient.
It was found that 60% of the patients had complete
coincidence of the records in all directions and 40%
had an average of 0.2 mm of dispersion in all
directions. The authors concluded that chin point
guidance was a repeatable method of centric rela-
tion registration.
Simon and Nicholls5 studied the variability of
passively recorded centric relation. Three different
centric relation records were repeated 5 times on 5
patients. The average range of shift was 0.3 mm
mediolaterally and 0.2 mm anteroposteriorly for all
subjects. The authors concluded that there were no
significant differences among the methods, and
that centric relation was a repeatable position.
91
Hellsing and McWilliam6 tested the repeatabil-
ity of centric relation mandibular position by radi-
ography. In an earlier pilot study,7 the same group
demonstrated that subtraction radiology offered
precision in detecting small differences in condylar
position when centric relation was registered with
bimanual mandibular manipulation and chin point
guidance. Using the same model, they also showed
that these 2 methods of recording centric relation
resulted in condylar positions that did not differ
significantly from one another.8 The group’s 1985
study6 focused on the repeatability of the 1-hand
(thumb) push-back technique using the same ra-
diographic method. The results showed that the
mandibular condyles were seated in a reproducible
position. Individual variation between the left and
right condylar position on each subject was larger in
the vertical plane than in the horizontal plane.
Between subjects, condylar position showed more
horizontal variation, although vertical variation was
also high.
Hobo and Iwata9 considered centricity of the
condyles, reported earlier,10-13 as a distinguishing
criterion of centric relation records. They studied
the repeatability of mandibular centricity using an
electronic instrument similar to the Pantronic
(Teledyne Water Pik, Fort Collins, CO). The pur-
pose of the study was to evaluate different tech-
niques for condylar positioning and to record the
amount of condyle displacement in 3 dimensions
with a newly developed electronic mandibular re-
cording system. The centric recording techniques
used in the study were (1) unguided closure, (2)
chin point guidance, and (3) bimanual manipula-
tion. The investigation on 10 adults concluded that
all methods had 0.2– 0.3 mm of condylar displace-
ment. The authors related this displacement to the
philosophy of freedom in centric and did not con-
sider this a drawback to the use of centric records.
The most repeatable method was bilateral manip-
ulation. Chin point guidance positioned the con-
dyles posterior, inferior, and right lateral. Un-
guided recording, although better than chin point
guidance, revealed slight lateral displacement.
Piehslinger et al14 examined the reproducibility
of condylar position at the point of unstrained hinge
movement of the mandible in subjects with tem-
poromandibular joint disorders and in asymptom-
atic subjects. This was the location that they re-
ferred to as “centric relation.” They considered 3
factors: (1) repeatability of each operator, (2) re-
92 Replicability of Centric Relation Registration ●
peatability with symptomatic versus asymptomatic
patients, and (3) repeatability between operators.
The results showed that none of these factors had a
significant influence on reproducibility of the con-
dylar reference position; that is, condylar position
was repeatable in all conditions. The authors sug-
gested using a physiologic area of reference, be-
cause most of the condylar positions reproduced
were located within 0.2 mm of each other.
Wood and Elliot15 used the condylar position
indicator (Panadent, Grand Terrace, CA) to exam-
ine the reproducibility of Roth’s centric relation
method.16 The condylar displacement for 39 sub-
jects was measured in the vertical and horizontal
directions from mounted casts. A centric relation
bite registration was taken 5 times every 5 days and
used to remount the lower cast and record the data
5 times. The authors found no significant difference
between the 5 condylar position indicator readings,
and they concluded that Roth’s centric relation bite
registration was highly reproducible.
Tripodakis et al17 conducted a clinical study of
the location and reproducibility of 3 mandibular
positions in relation to body posture and muscle
function. They used 3 reference positions: (1) cen-
tric occlusion, (2) electromyographic biofeedback
neuromuscular position, and (3) bilateral manipu-
lation. The reproducibility of centric occlusion was
found to be less than that of centric relation but
greater than that of neuromuscular position. Body
position or use of the splint did not affect the
location of centric occlusion. The reproducibility of
centric relation was not affected by body position
but was affected by the splint, which led to a more
precise posterior location that these authors consid-
ered ideal.
Harper and Schneiderman18 designed a study to
compare the reproducibility of the condylar trans-
lation pathway (from centric relation to centric
occlusion) and the centric relation position in pa-
tients with and without internal derangement of
the temporomandibular joint. Fifteen patients with
internal derangement and 15 healthy control pa-
tients carried out SAM axiography in 3 separate
recording sessions. Analysis of the condylar move-
ment pathway revealed greater reproducibility in
the control group with both right and left condyles.
The authors concluded that the concept of centric
relation in the normal temporomandibular joint
must include a dynamic range of horizontal (coro-
Keshvad and Winstanley
nal) adaptations to potential biomechanical and
biologic stress related to oral function.
McKee19 designed a study to determine whether
a standardized method of achieving centric relation
(bimanual manipulation) would be repeatable
within the 0.1-mm tolerance of the Denar Centri-
Check instrument (Teledyne Water-Pik) used to
examine condylar location of centric records. A
control group of 132 dentists and an experimental
group of 11 dentists all made centric relation
records on the experimental group. The control
group used individual preferred recording tech-
niques, whereas the experimental group used the
bimanual method to determine centric relation.
The control group could not repeat the position
within the 0.1-mm tolerance of the Centri-Check,
whereas the experimental group could do so in 106
of 110 first attempts and in 4 of 4 subsequent
attempts. The results showed that centric relation
is a repeatable condylar position within 0.1 mm
when the bimanual manipulation method was used.
Most of the studies in this field have compared
repeatability without having a constant and stable
reference point in space. In fact, an independent
point in space is needed to compare other mandib-
ular positions with each other. Another limitation
was the nonadjustability of intercondylar distance
in the devices that had been used. This factor may
affect calculations when records were measured at
an increased vertical dimension of occlusion. The
use of a leaf gauge, an anterior jig, and needlepoint
clutches in centric relation records, along with the
fact that clearance was necessary to accommodate
the bite registration material in dentate patients,
caused a raised bite.
The aim of the present study was to compare the
repeatability of 3 routinely used centric relation
records. The methods compared were (1) bimanual
mandibular manipulation with an anterior jig, (2)
chin point guidance with an anterior jig, and (3)
Gothic arch tracing.
Materials and Methods
Maximum intercuspation was used as a constant point to
compare the repeatability of 3 centric relation records. A
custom-made mandibular position indicator that allowed
for intercondylar distance adjustment was constructed on
a highly adjustable articulator. The mandibular position
indicator minimized errors during the remounting of
articulated casts to an analyzing device such as the Veri-
 June 2003, Volume 12, Number 2 93

Figure 1. Rear view of the Denar articulator with the Figure 2. Anterior jig constructed on the maxillary cast.
mandibular position indicator attached to the upper and
lower members. teeth. Maxillary and mandibular intraoral Gothic arch
tracing clutches (Condylator Service, Zurich, Switzer-
land) were made on the casts. A stylus was embedded in
check. The mandibular position indicator was designed to
autocure acrylic resin (De Trey; Dentsply, Dreieich, Ger-
be attached to the articulator and thereby enable a
many) to form the maxillary clutch on a line passing
comparison of the centric relation records for repeatabil-
between the first and second premolars on each side. A
ity (Fig 1).
tracing plate embedded in autocure acrylic resin was
No attempt was made to randomize subject selection,
formed for the mandibular arch (Fig 3). The stylus on the
because of the difficulty of recruiting individuals with an
maxillary clutch could be adjusted vertically by means of
occlusion that fulfilled all inclusion criteria for the study.
its screw, so that occlusal contact between the maxillary
Fourteen healthy Caucasian subjects (7 males and 7
and mandibular teeth just missed during lateral and
females), with an average age of 26.61 ⫾ 4.20, agreed to
protrusive movements.
participate in the study. Each subject satisfied the follow-
At the second visit, subjects were briefed on proce-
ing criteria:
dures and completed a questionnaire and consent form.
1. Good general health and normal dentition (free from The time interval requirement was adhered to scrupu-
developmental abnormalities) lously. In those few instances when subjects were late, the
2. No history of orthodontic treatment complete recording procedure was rescheduled. A face-
3. No extractions or missing teeth other than the third bow record was made using a Denar pantographic face-
molars bow (Teledyne Water Pik). The facebow was transferred
4. No evidence of temporomandibular joint pain or dys- to the Denar D4A articulator, and the maxillary cast was
function in the history or on clinical examination mounted using the support jig and 2-stage mounting
5. No evidence of bruxism or other parafunctional activ- media to limit setting expansion. Because all subjects had
ities. satisfactory occlusion, maximum intercuspation was des-
All clinical and laboratory stages were completed by 1 ignated as the reference point to compare the 3 centric
operator. Subjects received a complete intraoral and tem-
poromandibular joint examination and were asked to
make a number of further visits to carry out the experi-
mental work for each of the 3 methods.
At the first visit, maxillary and mandibular complete
arch impressions were made in metal stock trays using a
putty and reline addition-cured silicone impression ma-
terial (Provil; Bayer, Leverkusen, Germany) in 2 stages.
Casts were prepared using ADA type V die stone (Prima
Rock; Whip-Mix, Louisville, KY).
For each centric relation method, 2 anterior jigs were
made on the maxillary casts using Duralay (Reliance
Dental, Worth, IL) pattern resin (Fig 2) and trimmed Figure 3. Gothic arch tracing maxillary clutch (right)
and adjusted in the mouth, so that only 1 contact point holding the stylus and mandibular clutch (left) holding
occurred between the jig and the mandibular anterior the plate.
94 Replicability of Centric Relation Registration ●
Figure 4. Schematic illustration of the left vertical plate.
The blue, yellow, red, and green points represent maxi-
mum intercuspation, the Gothic arch tracing, bimanual
mandibular manipulation, and chin point guidance mark-
ings, respectively, on the graph paper.
relation methods. The mandibular cast was related to the
maxillary cast and again mounted in 2 stages.
The condylar elements of the articulator were re-
moved, and the mandibular position indicator was
screwed to the upper and lower members (Fig 1). The
horizontal and vertical plate and stylus assemblies on
each side were adjusted to be perpendicular to each
other. Graph paper was attached to each plate, and the
styli marked the maximum intercuspation on the plates.
Different colors were used to mark each of the centric
relation records and maximum intercuspation on the
mandibular position indicator (Fig 4).
The third visit was the first centric relation registra-
tion. The subject was seated upright in the chair and
centric relation recorded by the method assigned.
Gothic Arch Tracing
Also called arrow-point tracing or needle-point tracing,
this active method of intraoral tracing was first intro-
duced by the Swiss anatomist Alfred Gysi.20 The method
was characterized as active because the subject’s mastica-
tory musculature was active during registration and the
dentist had little involvement in directing the mandible
into centric relation. To program an adjustable articula-
tor, Gysi developed this as an extraoral method, but it
was later revised and modified by Gerber et al21 to be an
intraoral method. In this study, maxillary and mandibu-
lar lower clutches made using the technique described
earlier were inserted into each subject’s mouth. Absence
of tooth interference in mandibular horizontal move-
ments was verified. The mandibular plate was painted
with blue crayon, and the subject was instructed to carry
out extreme lateral and protrusive mandibular move-
ments. The path of movement scribed by the stylus on
Keshvad and Winstanley
the plate was triangular in shape, with the apex pointing
anteriorly toward the front of the mouth. The centric
relation registration was not considered correct until the
apex of the tracing was sharp and thin. This apex corre-
sponds to the position of the mandible in centric relation.
A transparent plastic disc with a small opening in the
middle was secured to the mandibular plate with sticky
wax so that the center of the opening was superimposed
on the apex of the Gothic arch tracing (Fig 5) with the
beveled side uppermost. The patient’s mandible was then
directed so that, on closing, the stylus entered the hole in
the plastic disc. Silicone bite registration material (Jet
Bite; Bayer, Leverkusen, Germany) was injected in the
interarch space while the subject held the mandible in
centric relation.
Bimanual Mandibular Manipulation
With Jig
This passive method of recording centric relation was
described by Long22 and modified by Dawson.23 In this
technique, the anterior jig or deprogrammer was ad-
justed and placed onto the anterior teeth. The jig was
trimmed gradually and checked intraorally to achieve the
smallest opening while the teeth were just out of contact.
Using articulating ribbon, 1 point of mandibular anterior
tooth contact was established on the palatal surface of
the jig. It was important that only 1 point of contact was
established, because the existence of any other point
would confuse the subject as to which point of contact he
or she should close and also could cause the mandible to
deviate.
When the subject was comfortable with the jig, it was
retained for 15 minutes in the mouth, to deprogram the
habitual occlusion. Dawson’s technique of centric rela-
tion registration23 was carried out consecutively, and the
mandible was manipulated while the jig was on the
anterior teeth. The technique entailed working from a
Figure 5. The opening in the transparent plastic disc
superimposed on the apex of the Gothic arch tracing.
 June 2003, Volume 12, Number 2
Figure 6. The mandible is locked in the centric relation
position before the bite registration paste is injected.
seated position behind the subject with the subject re-
laxed and the head stabilized. The 4 fingers of each hand
were positioned on the lower border of the mandible, with
the little fingers level with the angle, and the thumbs
were brought together to fit in the notch above the
symphysis. Gentle manipulation was then carried out
when it was felt there was no muscle stiffness and the
mandible was hinging freely. To standardize the registra-
tion technique, a mandibular lock was needed to hold the
mandible in centric relation. This was achieved by plac-
ing a small amount of light-cured composite resin on the
palatal surface of the anterior jig. When centric relation
was established, the mandibular incisors were tapped
into the composite resin on the jig and cured in place.
The mandible was then guided into the impression of the
incisors on the composite resin before the same bite
registration material was injected (Fig 6).
Chin Point Guidance With Jig
This passive method of 1-handed manipulation was de-
scribed by Ramfjord and Ash24 and Ash and Ramfjord,25
although McCollum26 was probably the first to report it
in the literature. In the past, this method was called the
“3-finger” method because the thumb, index finger, and
middle finger were all placed on the chin and the man-
dible was pushed as far posterior as possible. The method
has been modified,25 with the thumb placed on the mid-
point of the chin and the other 2 fingers supporting the
mandible inferiorly. To record centric relation with this
technique, the thumb, index finger, and middle finger
were used to manipulate the mandible in a hinging
manner. The thumb was placed intraorally approxi-
mately on the infradentale point. The index and middle
fingers were placed on the inferior border of the mandi-
ble to prevent lateral displacement during recording (Fig
7). The same custom-made anterior jig and use of com-
posite resin as in the bimanual mandibular manipulation
95
Figure 7. Manipulation of the mandible to centric rela-
tion by the chin point guidance technique.
method was used. The locking effect of the composite
resin eliminated any displacement of the mandible while
the patient was biting.
At the next 3 visits (visits 4, 5, and 6), scheduled for 1
hour, 1 day, and 1 week after the first (baseline) centric
relation recording visit, the same 3 methods were re-
peated. At baseline and 1 hour, the bite registrations had
already been marked on the mandibular position indica-
tor to prevent dimensional changes of the bite registra-
tion material. The 1-day and 1-week centric relation
records were marked on the mandibular position indica-
tor plates, and the plates were analyzed.
The marking procedure was as follows. The records
were placed individually between the maxillary and man-
dibular casts that had already been mounted using face-
bow and maximum intercuspation records. One record
was placed on the mandibular cast, and the maxillary
member of the articulator was related to it. To stabilize
the members of the articulator and prevent distortion at
the time of the markings, it was necessary to apply
pressure on the top of the articulator. A 2-kg load was
Figure 8. A 2-kg load on the articulator to standardize
pressure.
96 Replicability of Centric Relation Registration ● Keshvad and Winstanley

Table 1. Values of repeatability study. X, Y and Z values indicate antero-posterior, supero-inferior and medio-
lateral movements from maximum intercuspation (MI) respectively. Values of this table were extracted from the
first CR record; i.e.; the baseline record.
LEFT mm RIGHT mm
GAT BMM CPJ GAT BMM CPJ
X Y Z X Y Z X Y Z X Y Z X Y Z X Y Z
Mean 1.3 3.6 0.0 0.5 2.1 ⫺0.2 0.7 2.2 ⫺0.2 1.1 3.6 0.1 0.4 2.0 0.3 0.5 2.3 0.0
SD 1.2 1.7 0.7 1.0 0.8 0.5 1.2 0.7 0.6 0.7 1.5 0.7 0.7 1.0 0.5 0.7 0.8 1.0
MAX 4.0 6.4 2.0 3.4 3.5 1.0 4.0 3.3 1.3 2.9 5.4 1.2 1.4 3.8 0.9 2.0 4.0 1.2
MIN ⫺0.6 ⫺0.2 ⫺1.1 ⫺0.7 1.0 ⫺0.8 ⫺0.3 1.0 ⫺1.3 0.0 0.0 ⫺1.9 ⫺1.2 0.3 ⫺1.1 ⫺0.5 1.1 ⫺2.9

applied each time to standardize the pressure (Fig 8),
and, because the condylar elements were removed, the
only contact between the upper and lower members of
the articulator was the centric relation record.
The plates of the mandibular position indicator were
detached, and the marks were examined with a stereomi-
croscope (Olympus OM-2 BHM metallurgical micro-
scope; Olympus Optical, Tokyo, Japan). The microscope
was modified to accept the plates by means of an alumi-
num platform attached to the existing platform. A cross
graticule was added to the right viewfinder of the micro-
scope to enable the operator to adjust the center of the
cross to the maximum intercuspation marking on the
graph paper. Maximum intercuspation was considered
the center of a Cartesian coordinate system. At this
point, all microscope adjustments were set to 0. With
these settings, it was possible to measure mandibular
displacements in all directions. Maximum intercuspation
was taken as the starting point for comparing the man-
dibular position of different centric relation registrations.
The distance between each maximum intercuspation and
each of the centric relation dots on the graph paper was
measured, in millimeters, by the vernier scale of the
microscope to an accuracy of 0.1 mm.
The mandibular position indicator had 4 plates, 2 on
each side, and thus it was possible to indicate the differ-
ences between the records in 3 directions: anteroposte-
rior (x axis), superoinferior (y axis), and mediolateral (z
axis). At the conclusion of the recordings for the subjects,
each plate had 13 markings in different colors for each
centric relation technique. One maximum intercuspation
marking (in blue), 4 bimanual mandibular manipulation
markings (in red), 4 Gothic arch tracing markings (in
yellow), and 4 chin point guidance markings (in green).
Results
Statistical analysis was carried out using Microsoft
Excel and SPSS for Windows. Tables 1– 4 provide
summaries of the data obtained directly from the
microscope. Table 1 displays the data obtained
from the first centric relation session (visit 3, base-
line), and Tables 2– 4 present the 1-hour, 1-day, and
1-week data, respectively. These tables indicate the
distance of each centric relation record in a specific
direction from maximum intercuspation. Compar-
ing the values of each method in each direction
from all 4 tables indicated whether a method was
repeatable. The repeatability of each method was
compared relative to the repeatability of the other
methods.
In Table 1, the mean variability of the Gothic
arch tracing in the x axis (anteroposterior) shows
1.3 mm of anterior displacement with 1.2 mm of
standard deviation. The MAX box shows the max-
imum anterior displacement from maximum inter-
cuspation, which was 4 mm in this table, and the

Table 2. Values of repeatability study. X, Y and Z values indicate antero-posterior, supero-inferior and medio-
lateral movements from maximum intercuspation (MI) respectively. Values of this table were extracted from the
second CR record; i.e., the one hour time interval record.
LEFT mm RIGHT mm
GAT BMM CPJ GAT BMM CPJ
X Y Z X Y Z X Y Z X Y Z X Y Z X Y Z
Mean 1.2 3.8 ⫺0.2 0.5 2.1 ⫺0.2 0.6 2.1 0.0 1.3 3.8 0.2 0.5 2.1 0.3 0.4 2.1 0.1
SD 1.0 1.4 0.6 1.0 0.8 0.6 1.0 0.6 0.5 0.7 1.4 0.5 0.9 1.0 0.6 0.7 0.8 0.5
MAX 3.2 6.4 1.3 3.2 3.5 1.3 3.2 3.3 1.3 3.2 6.8 1.2 2.0 3.8 1.2 1.8 4.0 0.9
MIN 0.2 1.4 ⫺1.2 ⫺0.5 0.8 ⫺1.0 ⫺0.3 1.2 ⫺0.8 0.6 1.2 ⫺1.0 ⫺1.2 0.3 ⫺1.0 ⫺0.5 1.1 ⫺1.0
 June 2003, Volume 12, Number 2 97

Table 3. Values of repeatability study. X, Y and Z values indicate antero-posterior, supero-inferior and medio-
lateral movements from maximum intercuspation (MI) respectively. Values of this table were extracted from the
third CR record; i.e.; the one day time interval record.
LEFT mm RIGHT mm
GAT BMM CPJ GAT BMM CPJ
X Y Z X Y Z X Y Z X Y Z X Y Z X Y Z
Mean 1.4 3.5 ⫺0.1 0.5 2.2 ⫺0.2 0.5 1.9 ⫺0.1 1.2 3.3 0.2 0.4 2.1 0.2 0.3 1.8 0.2
SD 1.0 2.0 0.7 1.0 1.0 0.6 1.0 0.9 0.7 1.0 1.6 0.7 0.9 0.8 0.6 0.7 0.8 0.5
MAX 3.4 5.6 1.3 3.2 4.2 1.3 3.0 3.6 1.4 2.9 5.4 1.2 2.0 3.3 1.2 1.7 3.2 1.2
MIN ⫺0.1 ⫺0.9 ⫺1.3 ⫺0.7 1.0 ⫺1.0 ⫺0.5 0.9 ⫺1.3 ⫺0.7 ⫺0.2 ⫺1.1 ⫺1.5 0.9 ⫺1.1 ⫺1.0 ⫺0.8 ⫺1.0

MIN box shows ⫺0.6 mm, the most posterior posi-
tion of the mandible relative to maximum intercus-
pation in 14 patients. These results could be com-
pared with the corresponding results in the tables
that follow, which showed the results after 1 hour, 1
day, and 1 week.
To identify the most repeatable method, a
2-tailed F test was carried out. In a test of this type,
it was necessary to observe the repeatability of the
method pairwise and then deduce which method
showed the highest repeatability. Left and right
sides were analyzed separately and the data were
tabulated so that each method, side, and axis was in
1 table. Using the variation within and between the
subjects, the F and corresponding p value of the
specific comparison were calculated. The results of
the F tests on both sides are summarized in Tables
5–7. Interpretation of the data involved examina-
tion of the F values of each comparison. For exam-
ple, from the left side of Table 5, it can be seen that
bimanual mandibular manipulation was 4.14 times
more repeatable than chin point guidance and 1.82
times more repeatable than the Gothic arch trac-
ing. Chin point guidance was 0.43 times more re-
peatable than the Gothic arch tracing. On the right
side for the same axis of displacement, the figures
were quite different, showing that there was an
element of asymmetrical displacement between the
right and left sides in all 3 centric relation records.
On this side, bimanual mandibular manipulation
was only 1.23 times more repeatable than chin
point guidance and 3.63 times more repeatable
than the Gothic arch tracing. Chin point guidance
was 2.93 times more repeatable than the Gothic
arch tracing. The other 2 tables showed the differ-
ences in the y and the z axes of displacement. It was
also necessary to look at each individual p value for
the interpretation of the data.
Because the test was a 2-tailed F test and the
type I error was 0.05, there were low and high limits
(0.025 ⬍ p ⬍ 0.975) in the distribution. Therefore,
each p value greater than 0.975 or smaller than
0.025 indicated significance in repeatability.
The overall result of the comparisons showed
that bimanual mandibular manipulation was the
most repeatable method in all 3 axes and the
Gothic arch tracing was the least repeatable. The
degree of repeatability between the methods in
different axes varied.
Graphical representation of the data helps in the
understanding of the multiple comparisons and
gave better visualization of the repeatability. The
data of the 14 subjects are presented in Figure 9,
where all methods and axes are included in a 3-di-

Table 4. Values of repeatability study. X, Y and Z values indicate antero-posterior, supero-inferior and medio-
lateral movements from maximum intercuspation (MI) respectively. Values of this table are extracted from the
fourth CR record; i.e.; the one week time interval record.
LEFT mm RIGHT mm
GAT BMM CPJ GAT BMM CPJ
X Y Z X Y Z X Y Z X Y Z X Y Z X Y Z
Mean 1.3 3.8 ⫺0.1 0.6 2.0 0.0 0.7 2.3 0.0 1.0 3.7 0.1 0.5 2.1 0.1 0.3 2.0 ⫺0.1
SD 1.0 1.5 0.6 1.0 0.7 0.6 1.0 1.3 0.6 0.7 1.3 0.6 0.7 0.9 0.5 0.7 0.8 0.7
MAX 3.6 6.0 1.4 2.9 3.2 1.4 3.0 5.6 1.4 2.0 5.8 1.0 1.8 4.0 1.0 1.8 4.0 1.0
MIN ⫺0.3 1.0 ⫺1.0 ⫺0.7 1.0 ⫺1.0 ⫺0.5 0.8 ⫺1.0 ⫺0.8 1.2 ⫺1.1 ⫺0.5 1.3 ⫺1.0 ⫺0.8 1.1 ⫺1.9
98 Replicability of Centric Relation Registration ●
Table 5. The result of the F-test on X axis (antero-posterior),
LEFT X AXIS
BMM CPJ
BMM F ⫽ 4.149
CPJ P ⫽ 0.99*
GAT P ⫽ 0.96 P ⫽ 0.005*
*denotes significance
mensional scattergram on the left side. It was pos-
sible to actively rotate the cube or enlarge it to view
the data from every possible angle. An angle that
showed most of the points in good perspective has
been selected. The Gothic arch tracing points were
more scattered than those of the other 2 methods.
The concentration of bimanual mandibular manip-
ulation points in the middle of the cube was an
indication of its relative repeatability compared
with the other 2 methods. Figure 10 is the graphic
view of the right temporomandibular joint area
from a different perspective. The distribution of the
records was similar to that on the left side and
confirms the results of the analysis indicating bi-
manual mandibular manipulation as the most re-
peatable method.
Discussion
Centric relation is regarded as a valid reference
position for certain clinical treatment modalities.
However, it is difficult to know that this position has
been recorded with the condyle– disc complex in the
anatomical position of centric relation. The Glos-
sary of Prosthodontic Terms2 states that centric
relation occurs when the condyle is located in the
most anterior superior position of the temporoman-
dibular joint against the posterior slope of the gle-
noid fossae. This is an anatomical position, and as
such it cannot be substantiated clinically, because
no particular technique or system can confirm ex-
actly where the condyle– disc complex is located in
the temporomandibular fossa. The use of radio-
Table 6. The result of the F-test on Y axis (supero-inferior),
LEFT Y AXIS
BMM CPJ
BMM F ⫽ 1.67
CPJ P ⫽ 0.94
GAT P ⫽ 1* P ⫽ 0.99*
*denotes significance
Keshvad and Winstanley
RIGHT X AXIS
GAT BMM CPJ GAT
F ⫽ 1.820 F ⫽ 1.23 F ⫽ 3.63
F ⫽ 0.438 P ⫽ 0.74 F ⫽ 2.93
P ⫽ 0.99* P ⫽ 0.99*
graphs, computed tomography, or magnetic reso-
nance imaging may indicate whether the condyle is
in the “correct” position, but their routine use
cannot be ethically justified.
This study has shown statistically that bimanual
mandibular manipulation is the most repeatable
method of the 3 methods used in the investigation.
Repeatability of a reference point, such as centric
relation, is of clinical significance because it is the
only feasible way of evaluating the record clinically.
It is a method recommended by some authors.3,5 It
can be tested by radiographic8 or mechanical meth-
ods,4 such as was used in this study, where subjects
are not exposed to ionizing radiation, and is cost-
effective and reliable.
A qualitative evaluation of centric relation can
be carried out simply by superimposing a series of
records in a mandibular position indicator. How-
ever, handling data that require accurate repeat-
able quantification is more complex. The temporo-
mandibular joint is a unique diarthrotic joint,
capable of moving in many directions. An accurate
measuring system, such as an electronic or mechan-
ical mandibular positioning indicator, should be
capable of registering mandibular shifts in all di-
rections. The data extracted from such a device will
be complex, because a value is recorded for each
mandibular shift in a specific direction. Left- and
right-side values add to the complexity. There is a
natural asymmetry in all paired organs of the body,
and one cannot expect anatomical structures of the
left and right temporomandibular joints, such as
muscles, ligaments, and osseous boundaries, to be
RIGHT Y AXIS
GAT BMM CPJ GAT
F ⫽ 7.80 F ⫽ 1.10 F ⫽ 5.56
F ⫽ 4.67 P ⫽ 0.61 F ⫽ 5.05
P ⫽ 1* P ⫽ 0.99*
 June 2003, Volume 12, Number 2
Table 7. The result of the F-test on Z axis (medio-lateral),
LEFT Z AXIS
BMM CPJ GAT
BMM F ⫽ 1.075 F ⫽ 1.37
CPJ P ⫽ 0.58 F ⫽ 1.27
GAT P ⫽ 0.83 P ⫽ 0.77
* denotes significance
completely symmetrical. Therefore, it is natural
that the left and right temporomandibular joints
should give different values, adding to the difficulty
of recording centric relation.
Unlike some studies,19,27 the present study in-
cluded more than 1 centric relation method in the
investigations, so that in comparison (and rela-
tively), repeatability in all directions and on all
sides could be determined for each. Left and right
sides were analyzed separately, and the results
of both sides were considered in drawing a final
conclusion. Bimanual mandibular manipulation
showed a greater repeatability for both sides of the
temporomandibular joint than the other 2 meth-
ods. The repeatability of chin point guidance was
better than the Gothic arch tracing, although the
results were closer to those of bimanual mandibular
manipulation. This is probably because both biman-
ual mandibular manipulation and chin point guid-
ance are passive methods in which the operator
manipulates the mandible while a jig is placed
between the anterior teeth. One operator per-
formed all of the mandibular manipulation, so
there was only intraoperator variation, with no in-
teroperator error in recordings. With the Gothic
Figure 9. A 3-dimensional scattergram of the centric
relation methods in the left temporomandibular joint
area. Four time intervals set by technique (mm).
99
RIGHT Z AXIS
BMM CPJ GAT
F ⫽ 2.27 F ⫽ 10.11
P ⫽ 0.99* F ⫽ 4.45
P ⫽ 1* P ⫽ 0.99*
arch recordings, the operator had a minimal role
after briefing the subject about the mandibular
excursions, so that other variables, such as muscle
fatigue, time of day, and even emotional factors,
could have affected these results.
It is important to state that, because there is no
standard limit in the literature for the magnitude
of variability of centric relation records, it is recom-
mended that 3 or more records be compared to
determine which 1 is more repeatable. Comparing
the results of different studies would be misleading,
because each study has its own design, subject
selection, and statistics. Grasso and Sharry3 re-
peated the Gothic arch tracing for a longer period
and achieved results similar to those found in this
study. Tracings repeated a month later showed
variability in mediolateral and anteroposterior di-
rections, with the former showing more variability.
Other studies investigating repeatability of centric
relation records all compared bimanual mandibular
manipulation and chin point guidance with or with-
out an anterior jig. Shafagh and Amirloo,4 Elliot,28
and McKee19 investigated 1 method of recording
centric relation. Such studies can show a range of
mandibular dispersion in only 1 specific centric
Figure 10. A 3-dimensional scattergram of the centric
relation methods in the right temporomandibular joint
area. Four time intervals set by technique (mm).
100 Replicability of Centric Relation Registration ●
relation record. However, in other studies, compar-
isons are unacceptable; for example, Tripodakis et
al17 compared the repeatability of centric relation,
centric occlusion, and neuromuscular position. Al-
though there currently is no debate about the dif-
ference between centric relation and centric occlu-
sion, the literature indicates that “neuromuscular”
is a word no longer in regular use and is not
compatible with centric relation.29
In the present study, the decision was made to
select not only the most popular methods, but also
those methods most similar to each other. All of
these methods record centric relation mandibular
position and use a deprogrammer to eliminate the
effect of this variable in the study. There is at least
1 study in the literature showing that the operator’s
role in the repeatability of centric relation records
is negligible.14 In the present study, it was also
shown that the repeatability of bimanual mandib-
ular manipulation and chin point guidance were
very close, with the former indicating more consis-
tent repeatability. This finding is supported by the
results of another study with a similar design that
compared the repeatability of these 2 methods.5
Another factor that could affect the result of the
study is bite force, which can cause mandibular
displacement during centric relation registra-
tion.30,31 The use of an anterior jig and the locking
mandibular system used in this study ensured that
the mandible was in centric relation while there
was no bite force. As soon as the subject bites hard
on the jig, the composite is debonded from the
anterior jig, and the record is void.
Conclusions
Based on the results of the present study, the
following conclusions can be drawn:
1. Bimanual mandibular manipulation used with
an anterior jig gave the highest repeatability
among all the centric relation recording meth-
ods used in the study. Chin point guidance pro-
vided the second most repeatable method, and
the Gothic arch tracing showed the least repeat-
ability among the 3 methods.
2. Left and right temporomandibular joints showed
different degrees of repeatability with each of
the 3 centric relation methods.
Keshvad and Winstanley
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