What Materials and Reproducible Techniques May Be Used in

Recording Centric Relation? Best Evidence Consensus

Statement
Mathew T. Kattadiyil, BDS, MDS, MS ,1 Abdulaziz A. Alzaid, BDS, MS,2,3 & Stephen D. Campbell, DDS,
MMSc 4
1
Advanced Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, CA
2
Prosthetic Dental Science Department, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International
Medical Research Center, Riyadh, Saudi Arabia
3
Prosthodontics and Digital Technology, Loma Linda University School of Dentistry, Loma Linda, CA
4
Restorative Dentistry, University of Illinois at Chicago, Chicago, IL

Keywords
Centric relation; interocclusal records; centric
relation accuracy; centric relation
reproducibility; centric relation technique.
Correspondence
Mathew T. Kattadiyil, 11092 Anderson Street,
Loma Linda, CA 92350.
E-mail: mkattadiyil@llu.edu
Disclosure: No conflict of interest
Accepted December 17, 2020
doi: 10.1111/jopr.13321
Abstract
Purpose: The purpose of this Best Evidence Consensus Statement was to evaluate
the existing literature relative to two focus questions: What are the techniques used
and their reproducibility in recording centric relation (CR) in a dentate and partially
dentate population and what effect do different recording materials have on the re-
producibility of CR?
Materials and Methods: Keywords used in the initial search were: CR, interocclusal
records, CR accuracy, CR reproducibility, and CR technique. The search was then
limited to Systematic Reviews, Randomized Controlled Studies, Meta-analyses, and
Clinical Trials.
Results: Initial search related to the selected search terms resulted in more than 3500
articles. When subsequent search was limited to Systematic Reviews, Randomized
Controlled Studies, and Meta-Analysis and Clinical Trials, this resulted in 291 articles
selected for further analysis.
Conclusions: Techniques using chin point guidance, bimanual manipulation, power
centric, Gothic arch tracing, leaf gauge, and anterior deprogramming devices to
record CR can all be comparable in precision and clinical accuracy in regards to
clinical relevance. Practitioner experience and familiarity with a particular technique
is critical for accuracy when recording CR. Polyvinyl siloxane and polyether consis-
tently performed better in the broad range of studies on recording materials. Virtual
capture of CR could serve as a comparable recording medium but requires further
clinical study.

Centric relation (CR) is a condylar position that has been de-
bated and extensively studied. This observation is reflected in
the numerous changes in the definition of the term.1–7 In the
Glossary of Prosthodontic terms (GPT-8), there were seven
definitions for CR.6 There is support for the current defini-
tion of CR in the 9th Edition of the GPT,7,8 which defines
CR as “the maxillomandibular relationship, independent of
tooth contact, in which the condyles articulate in the anterior-
superior position against the posterior slopes of the articu-
lar eminences; in this position, the mandible is restricted to
a purely rotary movement; from this unstrained, physiologic,
maxillomandibular relationship, the patient can make vertical,
lateral or protrusive movements; it is a clinically useful, repeat-
able reference position.”
The Best Evidence Consensus Statement on the impact of
centric occlusion (CO) and maximal intercuspal position (MIP)
concluded that partially and completely dentate patients requir-
ing complete mouth rehabilitation should be restored in CO.
The purpose of this Best Evidence Consensus Statement is
to review the literature to answer focus questions related to re-
producibility of CR. Focus question 1: What are the techniques
used and their reproducibility in recording CR in a dentate
and partially dentate population? Focus question 2: What effect
do different recording materials have on the reproducibility of
CR?
To answer the focus questions, a search of the literature was
performed using terminology as it varied over time. As an ex-
ample, CR has been referred to as retruded condylar position,

34 Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists

Kattadiyil et al
retruded contact position, retruded axis position, and seated
condylar position.1–7 The varying terminology of CR has itself
led to confusion in the dental literature. The terminology used
in this article reflects the current edition of the GPT (GPT-9)
even if the literature referenced used older terminology.7
Focus question 1: What are the
techniques used and their
reproducibility in recording CR in a
dentate and partially dentate
population?
Search terms used were: CR and associated terms, CO, MIP,
technique, reproducibility, and accuracy.
The search strategy was related to the two focus questions
and limited to Systematic Reviews (SR), Randomized Con-
trolled Studies (RCT), Meta-analyses, and Clinical Trials. As
an example of the search process, initial search results for term
CR without any filters applied yielded 2096 results. Searches
for CO, MIP, technique and CR, reproducibility and CR and
accuracy and CR yielded 3,374; 155; 939; 183; 88 results, re-
spectively. Titles were reviewed and selected if they were re-
lated to the focus questions. When limited to SRs, RCT’s and
Meta-Analysis, and Clinical Trials among all search terms, 164
articles were selected for further analysis. The varying termi-
nology in prosthodontics over the years was addressed in the
report preparation. The terminology used in this article reflects
the current edition of the GPT.
Numerous techniques have been described in the dental liter-
ature for recording CR. Shanahan9 described the “swallowing
or free closure” technique. This method used the technique of
swallowing saliva for obtaining the occlusal vertical dimension
and CR. Schuyler10 described a technique where the patient
was asked to touch their palate with the tip of their tongue to
achieve condylar seating in CR. Gothic arch tracing or needle
point tracing described by Gysi11 is another method for record-
ing CR through utilization of intraoral or extraoral devices to
trace mandibular movements and locate CR as the apex posi-
tion of the Gothic arch. Another technique, “chin-point guid-
ance,” described by McCollum,12 focused on the significance
of the hinge axis position during CR recording. Dawson13 in-
troduced the “bimanual or bilateral manipulation” technique
to ensure seating the condyle in the most superior position of
the glenoid fossa. The mandible is guided superiorly with the
finger position of the clinician at the gonial angle while the
thumb simultaneously applies a downward pressure at the chin.
The technique using the Myo-monitor14 introduced by Jankel-
son, relied on stimulated rhythmic isotonic muscle contrac-
tions initiated by bilateral transcutaneous electric neural sim-
ulation of the stomatognathic system to achieve CR, referred
to as myocentric. Lucia15 introduced the technique of utiliz-
ing an anterior deprogramming device to separate maxillary
and mandibular teeth and stop the proprioceptive pattern re-
sulting from tooth contact, thus reprogramming the muscula-
ture to seat the condyle in the glenoid fossa. Long16 introduced
the leaf gauge to achieve separation of teeth to achieve CR.
Roth17 developed the “power centric” technique, where patient
musculature is used to seat the condyle in CR with the jaw sep-
arated to remove the influence of tooth contact.
Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists
Accuracy and Reproducibility of Centric Relation
The accuracy and reproducibility of CR and recording ma-
terials have been studied in the dental literature with varying
results.18–41 Grasso and Sharry18 evaluated the reproducibility
of the Gothic arch tracings on dentate subjects over a 29-day
period. Intraoral Gothic arch tracings were made at different
time intervals on 15 subjects. The authors reported that there
were significant changes in the apex position of the Gothic arch
tracing during the day and over the 29-day period.
Kantor et al19 conducted a study on 15 subjects compar-
ing reproducibility of CR recording using the following tech-
niques: swallowing, chin point guidance, chin point guidance
with Lucia jig (anterior deprogramming device), bilateral ma-
nipulation, and the Myo-monitor. Among all techniques, the
Lucia jig and bilateral manipulation had the most consistent
and reproducible recordings. They reported that the Myo-
monitor techniques showed considerable variations and were
700% less dependable compared to anterior deprogramming
and bilateral manipulation techniques.
Strohaver20 studied four methods for making CR records on
one subject. The author reported that among all techniques
studied, the myocentric position records made with the Myo-
monitor produced the least consistent recordings. Levinson21
studied the reproducibility of the anterior deprogramming de-
vice with bimanual manipulation. The author compared five
registrations of CR on each patient using the bilateral manip-
ulation technique and the anterior deprogramming techniques.
He concluded the anterior deprogramming device was more
reproducible in recording CR than those made by the bilateral
manipulation method.
In a study on 15 patients, Celenza22 evaluated recordings
made using a guided and non-guided biting point and Gothic
arch technique under magnification. The five subjects in this
study had recordings made 1 week apart over a 21-day period.
The author reported a discrepancy between four recordings and
four techniques. Although the range in discrepancy was small
(0.022 mm anteroposteriorly and 0.101 mm mediolaterally)
and not significant, the guided bite point recordings were more
consistent and revealed less errors than the nonguided record-
ings. The author reported difficulty in determining the apex of
the Gothic arch recording. There was no significant variation
in consistency for four of the five subjects studied over the
21 days.
Azarbal23 conducted a study on 20 individuals to compare
CO and MIP with centric positions obtained using the Myo-
monitor with Gothic arch recordings. Compared to the CR ob-
tained by using the Gothic arch recording, the author found
that Myo-monitor CR position in all subjects was anterior to
CO and MIP, by an average of 3.8 mm and 1.8 mm, respec-
tively. In 18 of the 20 patients, Myo-monitor recordings were
positioned laterally to CO and MIP. Noble24 in his study found
similar results, with CO posterior to the Myo-monitor centric
position, and that the Myo-monitor centric position was not
reproducible.
Shafagh and Amirloo25 in a study of 20 patients with An-
gle Class I occlusion examined the reproducibility of chin
point guidance with an anterior programmer device. Six
CR records were made for each patient. They reported that
60% of the patients had coincidence of all records in all
directions and 40% had an average difference of ± 0.2 mm
35
Accuracy and Reproducibility of Centric Relation
dispersion in all directions. The authors concluded that chin
point guidance with the anterior deprogramming device was a
repeatable method for recording CR.
Simon and Nicholls26 studied the variability of three differ-
ent CR recording techniques using chin point guidance, chin
point guidance with ramus support and bimanual manipulation
five times on five asymptomatic patients. They reported an
average shift of 0.278 mm anteroposteriorly and 0.302 mm
mediolaterally for all five subjects noting a small range of
mandibular positions in CO. They concluded that there was no
significant difference between the three techniques.
Hobo and Iwata27 evaluated the repeatability of CR with
unguided mandibular closure, to bimanual manipulation and
chin point guidance on 10 asymptomatic adults. They used
a system capable of measuring the three dimensions of the
mandible simultaneously. They reported no significant differ-
ences in condylar positions between the three techniques and
reported an average condylar discrepancy of 0.2 to 0.3 mm
with bimanual manipulation producing the most consistent
reproducibility.
Wood and Elliott28 used the Condylar Position Indicator to
study Roth’s power method of recording CR. This method ap-
plies a downward force on the chin while applying an upward
force at the angle of the mandible. They made one record each
day over 5 days on 39 dental students. They found no signifi-
cant differences between the condylar position indicator read-
ings over the 5 days, and concluded that the Roth technique
of CR recording was highly reproducible. They noted that the
condyle shifted inferiorly with a small distal component from
CR to MIP.
McKee29 performed a study on two groups of dentists
comparing the effect of standardization and training on CR
reproducibility. The study included 132 dentists called the
control group, who were asked to make CR records using their
preferred technique to an experimental group of 11 trained
dentists. A “centri-check” instrument was used to assess repro-
ducibility. The 132 dentists did not reveal consistent CR posi-
tion in any of their attempts. The 11 dentists in the experimen-
tal group were provided training with bimanual manipulation
and made CR records on each other with a 96.36% accuracy
within these subjects in their first attempt after training. They
subsequently achieved 100% accuracy in their second attempt.
The author reported that standardization and training could
significantly improve the ability to reproducibly record CR.
Tarantola et al30 reported a CO-MIP discrepancy study in-
volving 39 visiting dental faculty at the Pankey Institute, each
randomly assigned to one of five subjects who exhibited no
temporomandibular joint disorder (TMD) symptoms. The bi-
manual manipulation technique achieved repeatable results
with a maximum variation of 0.1 mm when recording CR as
measured with a Denar centri-check device. However, in one
instance, two dentists recorded CR that was different from the
others by several millimeters and the recording had to be re-
made. It was also noted that all dentists had prior training with
the CR recording technique.
Keshvad and Winstanley31 used a condylar position indicator
to evaluate four CR recordings on each of 14 healthy patients
made with three techniques; bimanual manipulation with an
anterior deprogramming device, chin point guidance with an
36 Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists
Kattadiyil et al
anterior deprogrammer, and Gothic arch tracing. They reported
that bimanual manipulation was the most reproducible tech-
nique in all 3 axes and Gothic arch tracing was the least repro-
ducible. However, the degree of reproducibility between tech-
niques in different axes varied. These findings are consistent
with other reports that evaluated Gothic arch tracings,18,32 but
contradicted Smith’s33 findings who reported that Gothic arch
recordings revealed the greatest t reproducibility compared to
the other techniques studied. Paixao et al34 in a study on 20
subjects evaluated five times with a 1-week interval, reported
better accuracy with Gothic arch tracing compared to bimanual
manipulation.
Schmitt et al35 evaluated interoperator and intraoperator re-
producibility of the Roth power centric technique in a study
performed on 18 patients with healthy temporomandibular
joints. Three dentists were trained and standardized on the
Roth method for CR recording and each completed CR record-
ing three times for each patient, producing 162 records. They
concluded that CR recording using Roth’s method resulted in a
high level of interoperator and intraoperator consistency. These
findings were supported in another study by Cordray.36
McKee37 compared condylar positions in CR captured with
bimanual manipulation and contracted masticatory muscula-
ture with an anterior deprogrammer in reclining and upright
positions for 11 patients by three dentists. He reported that
without occlusal teeth contact, the contraction of the mas-
ticatory musculature places the condyles in CR, within the
0.11 mm tolerance of the centri-check instrument, resulting in
a reproducibility comparable to bimanual manipulation.
Linsen et al38 evaluated condylar position reproducibility
with occlusal device therapy on 26 asymptomatic volunteers.
A three-dimensional electronic-condylar-position analysis was
recorded using an ultrasound-based jaw-tracking system. The
intermaxillary registrations of manually guided CR, MIP, and
clenching-force-dependent Gothic arch tracing guided CR
were recorded before and after occlusal device therapy. The
registration technique was found to have a significant effect
on condylar displacement in all axes before, and in X- and Y-
axes after device therapy. There were significant differences in
reproducibility of the condyle position dependent on the tech-
nique, before and after device therapy. The clenching-force-
dependent Gothic arch tracing guided CR method showed the
highest reproducibility, followed by MIP and manually guided
CR.
Kandasamy et al39 conducted a magnetic resonance imaging
(MRI) study on 19 patients evaluating various positions of the
condyle in the glenoid fossa using three different occlusal reg-
istration techniques, one at MIP and two techniques to achieve
CR (power centric and chin point guidance). They studied the
MRI’s and evaluated the right and left condylar positions for
the three techniques. They concluded that the occlusal regis-
tration techniques used could not precisely and predictably po-
sition the condyles in the glenoid fossae. They questioned the
clinical relevance of CR recordings. This is one of the few ar-
ticles that concluded predictably recording CR is not accurate.
The overwhelming majority of the literature does not support
this conclusion.
Galekovic et al40 in a study of 32 patients, compared the
reproducibility and reliability of CR for three techniques.
Kattadiyil et al
Bimanual manipulation, chin point guidance, and Roth’s power
centric method were examined using a mandibular position in-
dicator. The authors reported that all three techniques showed
equal accuracy and reproducibility for CR registration.
Discussion
It was noted that the historical literature overstated measure-
ment abilities in reporting mean values to the 0.001 mm level
(1.0 µm). This outcome appears to be the result of the aver-
aging of numbers that result in decimal place means that ex-
tend to tolerances beyond the measurement error. For example,
reporting shifts in condylar position of 0.278 mm, or percent-
ages of 96.36% are overstating the measurement sensitivity of
the studies. The numbers reported here represent the numbers
provided in the original articles for accurate reporting.
There is no clear evidence of one technique of recording CR
being inferior regarding reproducibility except for the Myo-
monitor technique which produced inconsistent and generally
poorer results. The variability of Myo-monitor centric is spec-
ulated to be due to the predominant masseter muscle contrac-
tion and limited contraction of the other muscles of mastication
with this technique. Also variations in electrode position, stim-
ulating current intensity, or resistance of skin and underlying
tissues could affect the position of the mandible.24
Bimanual manipulation, use of anterior deprogramming, leaf
gauge, and chin point guidance were comparable in repro-
ducibility and accuracy (Table 1). There is evidence that train-
ing and experience with chosen technique and accuracy of den-
tal materials used is associated with improved accuracy.41
Evidence-based conclusions
1. Techniques using chin point guidance, bimanual manip-
ulation, power centric, Gothic arch tracing, leaf gauge,
and Lucia jig to record CR can all be comparable in pre-
cision and accuracy with small differences that are not
clinically significant.
2. Among numerous techniques used for CR recording, no
technique has been found to be significantly superior to
others. Positive outcomes were observed for the anterior
deprogramming device and concept. A comprehensive
clinical study with a large patient population that com-
pares inter- and intraoperator variances, as well as the
broad range of available clinical techniques is lacking in
the literature.
3. Practitioner training, experience, and familiarity with a
particular technique is associated with clinical precision
when recording CR.
Focus question 2: What effect do
different recording materials have on
the reproducibility of CR?
The search terms included CR, CR and reproducibility, and in-
terocclusal records. Searches for CR, CR and reproducibility,
and interocclusal records.
The search yielded 2096; 183 and 376 results, respectively.
Titles were reviewed and selected if they were related to the fo-
cus questions. When limited to SRs, RCT’s and Meta-Analysis,
Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists
Accuracy and Reproducibility of Centric Relation
and Clinical Trials among all search terms, 127 articles were
selected for further analysis. Studies on the accuracy of CR in-
terocclusal recording materials provided insight in responding
to focus question 2.42–59
Assif et al42 measured changes in vertical dimension using
an electromechanical device in a study on 20 patients with
a double wafer of base wax, wafer of base wax coated with
zinc oxide-eugenol (ZOE) paste, acrylic resin, and polyether
(PE) interocclusal recording material. PE was the most accu-
rate among the four materials with a vertical discrepancy of 20
to 30 micrometers. Acrylic resin was the next most accurate
material, followed by wax and wax with ZOE paste.
Muller et al43 studied and compared the three dimensional
changes between maxillary and mandibular casts over differ-
ent time intervals (half hour, 6 hours and 24 hours). Eight
commonly used materials or combinations were tested that in-
cluded impression plaster, chemically activated resin, chemi-
cally activated resin combined with zinc-oxide eugenol (ZOE),
modeling plastic impression compound, hard pink wax, hard
pink wax combined with ZOE paste, impression compound
combined with ZOE, and polyether (PE). The authors con-
cluded that all the materials tested created asymmetric devi-
ations of the condyles after each storage period. Impression
plaster was found to be the most accurate and dimension-
ally stable material; PE was the second most accurate material
when used within 6 hours.
Urstein et al44 compared the accuracy of three recording ma-
terials to relate stone casts. Maxillomandibular relationships
were made on 15 dentate patients at MIP and CR using a Lu-
cia deprogramming device with impression plaster, wax, and
Duralay acrylic resin. The average percentage differences be-
tween the recording materials were calculated. Hand articula-
tion was found to be the most accurate method of relating the
casts at MIP. The most accurate recording medium was impres-
sion plaster, followed by dental wax and Duralay resin at MIP
and at CR.
Kong et al45 compared two conventional methods with Oc-
clusal Indicator Wax and Accufilm with the T-Scan system,
recording CR using the bimanual manipulation technique. The
patients (n = 14) were divided into two groups according to the
magnitude of CO-MIP discrepancy and comparisons of guided
closure contacts in CR were performed. Overall, all registra-
tion methods revealed significant agreement for identification
of contacts in CO. All methods had some false negative con-
tacts. The subjects with higher CO-MIP slides had less agree-
ment among methods in identification of guided closure con-
tacts in CR.
Breeding et al46 in an in vitro study, measured and compared
the accuracies of a thermoplastic resin, an acrylic resin, and a
polyvinyl siloxane (PVS) interocclusal recording material. A
computerized axiograph was used to record positional errors
in three planes that were adjacent to the posterior teeth, with the
three interocclusal recording materials. The authors reported
that all three materials revealed small but significant errors with
the thermoplastic material showing the greatest mounting error.
Campos and Nathanson47 studied two addition-reaction sil-
icone materials by obtaining eight interocclusal records with
each material on one patient (16 records total). Forces up to
6 kg were used to approximate maxillary and mandibular casts
37
Accuracy and Reproducibility of Centric Relation Kattadiyil et al

Table 1 List of relevant studies and information used to answer focus question 1

Sample
First Author Study type size Techniques examined Favorable technique Reproducibility

Grasso18 Clinical 15 Gothic arch NA No

Kantor19 Clinical 15 Swallowing, chin point guidance, Lucia jig and bimanual NA
chin point guidance with Lucia manipulation
jig, bilateral manipulation, and
Myo-monitor
Strohaver20 Clinical 1 Combination of techniques and Zinc oxide-eugenol NA
material utilizing a Lucia jig
Celenza22 Clinical 15 Guided and non-guided biting Guided bite point NA
point and Gothic arch
Azarbal23 Clinical 20 Myo-monitor and Gothic arch Gothic arch NA
Noble24 9 Myo-monitor NA No
Shafagh25 Clinical 20 Chin point guidance with an NA Yes
anterior programmer device
Simon26 Clinical 5 Chin point guidance, chin point No significant difference No
guidance with ramus support between the 3
and bimanual manipulation techniques
Hobo27 Clinical 10 CR with unguided mandibular Bimanual manipulation No
closure, bimanual
manipulation, and chin point
guidance
Wood28 Clinical 39 Roth’s power method NA Yes
McKee29 Clinical 11 Bimanual manipulation with NA Yes
training
Tarantola30 Clinical 39 Bimanual manipulation NA Yes
Keshvad31 Clinical 14 Bimanual manipulation with an Bimanual manipulation NA
anterior deprogramming
device, chin point guidance
with an anterior
deprogrammer, and Gothic
arch tracing
Smith33 Clinical 20 Terminal hinge axis, Gothic arch, Gothic arch NA
and empirical method
Paixao34 Clinical 20 Gothic arch tracing and bimanual Gothic arch NA
manipulation
Schmitt35 Clinical 18 Roth power centric NA Yes
McKee36 Clinical 11 Bimanual manipulation and Reproducibility was NA
contracted masticatory comparable with both
musculature with an anterior techniques
deprogrammer
Linsen37 Clinical 26 Manually guided CR, MIP, and Clenching-force- NA
clenching-force-dependent dependent Gothic arch
Gothic arch tracing guided CR tracing guided CR
before and after splint therapy
Kandasamy38 Clinical 19 MIP, power centric, and chin NA No
point guidance
Galekovic39 Clinical 32 Bimanual manipulation, chin All showed equal NA
point guidance, and Roth’s accuracy and
power centric reproducibility

to each other and the discrepancies from compression of the
silicone interocclusal records. The authors reported that no
significant changes were observed between the interocclusal
records with both PVS materials for loads up to one kilogram.
They concluded the materials could be used without changing
the recorded maxillomandibular relationship.
Eriksson et al48 examined clinical factors affecting re-
producibility of interocclusal recording methods. The repro-
ducibility of clinical occlusal records was assessed in three
dimensions using mounted casts. They evaluated five inte-
rocclusal records using eight materials (three different types
of waxes, two brands of PVS, irreversible hydrocolloid,

38 Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists

Kattadiyil et al
mounting plaster and ZOE paste, and variations seen in mount-
ing in CR and MIP). The study included three subjects from
three different cohorts that included one partially dentate, one
edentulous and one dentate patient. The authors concluded that
the main factor affecting reproducibility was the clinical tech-
nique rather than the type of recording material or the specific
mandibular position recorded. For the dentate patient, only one
of five mountings gave deviations less than 0.11 mm later-
ally, 0.07 mm anteroposteriorly and 0.04 mm vertically, and
only when a technique without interocclusal records was used.
They suggested that making one interocclusal record would not
always reproduce mountings in CR, thereby recognizing the
need for multiple records to confirm. The results are compro-
mised due to the low sample size.
Utz et al49 evaluated the reproducibility of CR recordings us-
ing different methods and materials. This study was conducted
on 81 completely dentate subjects and evaluated six differ-
ent recording materials: wax, plaster, compound, tin foil wafer
(0.9 mm thick tin foil layered with ZOE paste), acrylic resin
wafer, and refined wax wafer (wax wafer lined with zinc oxide
paste in the area of the maxillary cusps). The authors reported
that none of the techniques or materials provided an accurate
record. They concluded that despite the best technique or ma-
terial selected, that occlusal adjustments would invariably be
required. This article was an earlier study and most materials
included in this study are not currently used.
Vergos and Tripodakis50 conducted an in vitro study evalu-
ating the effect of occlusal registration material on the vertical
relationship of the mounted casts in MIP. Materials evaluated
were wax, acrylic resin, PE and PVS. A metallic apparatus
was made to represent teeth in occlusion with special com-
partments between upper and lower members of the appara-
tus to evaluate the vertical change following placement of bite
registration material by filling them with PVS material and
measuring its thickness. A duplicate of the apparatus was made
out of epoxy resin to represent dental casts. Measurements
were made in three phases; on the metallic apparatus after us-
ing the bite registration material, again on the metallic appara-
tus after repositioning the bite registration material and finally
on the epoxy resin models. All materials produced vertical dis-
crepancies with significant differences between them on the
apparatus. PVS produced the least vertical error (24 µm) fol-
lowed by PE (30 µm), acrylic resin (57 µm), and lastly wax
(74 µm). Following repositioning, greater vertical discrepan-
cies were found on the apparatus with the materials in the same
order of accuracy. When the records were transferred onto
the epoxy resin models, the vertical discrepancies were about
0.5 mm, without significant difference between the record-
ing materials. The authors concluded that vertical discrepan-
cies are inevitable with any occlusal registration material and
these discrepancies could be amplified when transferred to
the casts.
Michelakis et al51 evaluated the resistance to compression
after final polymerization of seven elastomeric inter-occlusal
recording materials which included four commercial brands
of PVS, polyether, ZOE paste, and wax. Resistance to com-
pression of each material was tested. Two loads, one of
100 g/cm2 and a second of 1000 g/cm2 were exerted on each
sample. The deformation of each material was calculated using
Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists
Accuracy and Reproducibility of Centric Relation
a vertical traveling micrometer microscope. PVS (Blu Mousse,
Parkell Inc., Edgewood, NY) displayed the greatest resistance
to compression, compared to the other elastomerics, wax and
ZOE interocclusal recording materials tested. Elastomeric ma-
terials performed better except for one brand (Regisil 2X,
DENTSPLY Caulk, Milford, DE) which showed the least re-
sistance to compression.
Michalakis et al52 performed an in vitro study for measuring
weight and linear changes following polymerization of differ-
ent interocclusal recording materials using an electronic scale
and traveling micrometer microscope. Materials studied were
PE, ZOE, wax, and four different brands of PVS. A mold
was made to shape the material into configurations that repre-
sented intraoral records. Measurements were made at five dif-
ferent time intervals: 0, 1, 24, 48, and 72 hours. The authors
concluded there was no correlation between linear changes
and weight changes. Polyether presented the smallest linear
changes for all the time intervals and the PVS materials had
statistically significant differences in linear changes between
them, at the 1st and the 24th hours. However, significant dif-
ferences were not observed after 48 hours.
Ghazal et al53 compared the accuracy of two types of wax
materials (Aluwax, Aluwax Dental Products Co., Allendale,
MI and Beauty Pink Wax, Miltex, Inc., York, PA) with PVS
and PE in an in vitro study. They reported that the PVS and PE
materials had better accuracy and the wax materials introduced
higher vertical discrepancies. Ghazal et al54 in a follow-up in
vitro study evaluated the same materials from their previous
study and added a composite resin material. PVS and PE mate-
rials performed better than the wax and composite resin materi-
als with regards to condylar displacement. Interestingly, when
a combination of composite resin and Aluwax technique was
used, this combination performed better than PVS and PE.
Sweeney et al55 studied the accuracy of five types of inte-
rocclusal recording materials that included two PVS materials,
two types of wax and a thermoplastic material for the articula-
tion of typodonts. The typodonts and the records were digitized
using a scanner and the accuracy of articulation of digital mod-
els determined. The authors reported that PVS records were
significantly more accurate than the other materials.
Úry et al56 conducted a clinical study to evaluate the accu-
racy of transferring gypsum casts from a conventional articula-
tor to a virtual environment using indirect digitalization. A total
of 194 analog points was considered in the reference. Ninety-
three percent of all analog points matched a virtual correspon-
dent, and 96% of the analog first contacts between the casts
were also present as first contacts in the virtual space. The true-
ness of the data transfer, corresponding to the spatial distance
between the matching analog and virtual points, was 0.55 ±
0.31 mm. The maximum recorded deviation was 1.02 mm.
Stafeev et al57 compared the precision of CR by various
methods: bilateral manipulation; modified Lucia jig depro-
grammer; leaf gauge; and intraoral Gothic arch recording using
a digital method of assessment. They reported that the most
reproducible CR was seen with the modified anterior depro-
grammer and the Gothic arch recording device. Radu et al58
described the use of an intraoral scanner to record CR with bi-
manual manipulation and an anterior deprogrammer for trans-
fer of CR to a virtual articulator.
39
Accuracy and Reproducibility of Centric Relation Kattadiyil et al

Table 2 List of relevant studies and information used to answer focus question 2

First Author Study type Material Evaluation method Variable examined Best material
42
Assif Clinical Doublewafer wax, wafer of Electromechanical Accuracy and vertical PE
base wax/ZOE paste, device displacement of
acrylic resin, and PE interocclusal recording
materials during the
transfer of
interocclusal
relationships to an
articulator
Muller43 Plaster, resin, chemically 3-D analyzer 3-D errors in mounting Impression plaster
polymerized resin/ZOE, casts affected by the followed by PE if
compound, wax, interocclusal recording poured within 6
wax/ZOE, materials hours
compound/ZOE and PE
Breeding46 Thermoplastic resin, acrylic Computerized axiograph Accuracy of interocclusal PVS, acrylic resin
resin, PVS recording materials better than
thermoplastic resin
Campos47 Clinical 2 PVS materials 3-D analyzer Compressibility of PVS
interocclusal recording
materials
Eriksson48 Clinical Wax, PVS, irreversible Cast measurement Reproducibility of None
Hydrocolloid, plaster and interocclusal recording
ZOEe
Vergos50 Laboratory Wax, acrylic resin, PE and Direct measurements Vertical accuracy of PVS
PVS interocclusal recording
materials
Michalakis52 Laboratory PVS, PE, ZOE and wax Electronic scale and Weight and linear PE
traveling micrometer changes following
microscope polymerization of
different interocclusal
recording materials
Ghazal53 Laboratory Wax, PVS, PE Inductive displacement Accuracy of interocclusal PVS and PE
transducer recording materials
Ghazal54 Laboratory Wax, PVS, PE, composite Inductive displacement Accuracy of interocclusal Wax/composite resin
resin, wax/composite transducer recording materials combination
resin followed by PVS
and PE
Sweeney55 Laboratory PVS, wax, and a Digital and direct Accuracy of interocclusal PVS
thermoplastic material measurements recording materials

Only a few studies have looked into MIP reproduc- Discussion

ibility.20,44,59 Strohaver20 and Urstein et al44 reported that hand
articulated casts produced the least variations among methods
for mounting casts in MIP. Jaschouz and Mehl59 studied 15
dentate patients comparing their MIP recorded at two differ-
ent time intervals and two different positions (supine and up-
right). They concluded that MIP could be achieved indepen-
dent from time of the day or subject position. Abdulateef et al60
in a clinical study on 10 subjects, evaluated the accuracy and
reproducibility of virtual interocclusal records with PVS in-
terocclusal records in MIP and reported comparable clinically
acceptable results. However, they observed undetected interoc-
clusal contacts and occlusal perforations between the opposing
virtual casts in MIP.
The authors of this article believe that a range of discrep-
ancies exist in determining and measuring CR due to mul-
tiple variables such as time of recording, technique, interoc-
clusal recording materials, clinical training, and experience.
CR recording materials such as impression plaster, PE, PVS,
combination of Aluwax with resin were determined to be con-
sistent and accurate (Table 2). PE and PVS are commonly
used and preferable in most clinical applications. Records
when digitized have shown that there is comparable trans-
fer of accuracy during this virtual process compared to ana-
logue methods. The use of intraoral scanning for recording CR
is a newer technique and has been reported.58 However, the

40 Journal of Prosthodontics 30 (2021) 34–42 © 2021 by the American College of Prosthodontists

Kattadiyil et al
accuracy of digital recording methods for jaw relationships has
not been studied.
Evidence-based conclusions
1. Variance occurs due to different recording materials,
techniques, as well as a circadian influence when
recording CR.
2. A single recording of CR introduces a greater potential
for error, and as a result multiple CR recordings should
be used to validate the recorded position.
3. Selecting interocclusal records that are repeatable (sim-
ilar) among multiple records improves accuracy. PVS
and PE revealed higher accuracy among contemporary
materials.
4. The small variations (100ths of an mm) seen in recording
CR do not appear to be clinically relevant.
Consensus conclusions
Techniques using chin point guidance, bimanual manipulation,
power centric, Gothic arch tracing, leaf gauge, and anterior de-
programming devices to record CR can all be comparable in
precision and clinical accuracy. Practitioner experience and fa-
miliarity with a particular technique is critical for clinical pre-
cision when recording CR. PVS and PE consistently performed
better than other recording materials. A comprehensive clinical
study with a large patient population that examines inter- and
intraoperator variance, compares contemporary materials and
technology as well as the broad range of available clinical tech-
niques is lacking in the literature. Virtual capture of CR might
serve as a comparable recording medium but requires further
clinical study.
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