Gnathology.

Oral Rehabilitation

DISCREPANCY BETWEEN CENTRIC RELATION AND HABITUAL

OCCLUSION AND TEMPOROMANDIBULAR DISORDER SYMPTOMS

Smaranda BUDURU1, Oana ALMĂŞAN2, Rareş BUDURU3, Mihai Ioan MIŢARIU4,

Mădălina MOROŞANU5, Mirela FLUERAŞU6, Mariana CONSTANTINIUC1
1
Associate professor, ”Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2
Lecturer, ”Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3
Dentist, ”Stomestet” Clinic, Cluj-Napoca, Romania
4
Associate professor, ”Victor Papilian” Faculty of Medicine, Sibiu, Romania
5
Dentist, ”Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
6
Univ. assistant, ”Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
Corresponding author: Oana Almăşan; e-mail: oana.almasan@umfcluj.ro

Abstract the fosa could be a risk factor for TMDs [4].

Introduction. The objectives of this study were to assess
the relationship between centric relation-habitual occlusion
discrepancy and temporomandibular disorder symptoms,
the spatial planes in which the discrepancy is encountered
and the correlation between gender and muscle pain.
Materials and methods. Thirty subjects (14 females, 16
males), aged between 20-30 years, were clinically evaluated,
as follows: muscle (temporalis, masseter, lateral and medial
pterygoid) and temporomandibular joint examination,
occlusal (static and dynamic) relationships, centric relation.
Casts were mounted in centric relation using an articulator
and then three-dimensionally analyzed. Results and
discussion. Muscle pain was found in 57.14% females and
37.5% males. Discrepancy was higher in subjects with pain
in all planes (transversal 0.92 mm vs. 0.26 mm [correlation
coefficient=0.897]; sagittal 0.94 mm vs. 0.85 mm [correlation
coefficient=0.249]; vertical 1.15 mm vs. 0.36 mm [correlation
coefficient=0.504]) and similar in males and females.
Conclusions. Transversal discrepancy was associated with
muscle pain. Muscle pain and discrepancy were not
correlated with gender.
Keywords: centric relation, habitual intercuspation
occlusion, discrepancy, muscle pain.
1. INTRODUCTION
The link between centric relation (CR)-
intercuspal position (IP) and its connection with
temporomandibular disorders (TMDs) has been
debated widely in the literature [1]. A discrepancy
between centric relation and intercuspal position
could predispose to temporomandibular
disorders [2]. The centric slide, known also as the
centric relation-maximum intercuspation (MIP)
discrepancy, is defined as “the movement of the
mandible while in CR, from the initial occlusal
contact into maximum intercuspation” [3].
Displacement of the mandibular condyle from
Occlusion and its role in TMDs is still debated
[5-7]. In subjects with TMDs, a discrepancy
between CR and MIP occlusion has been noted
[8,9], being associated with muscle pain [10].
Although many studies have reported a shift
between centric occlusion and maximum
intercuspation [11,12] a slide above 2 mm in the
vertical or horizontal plane is considered a
critical factor for TMDs [13]. For a precise occlusal
analysis of the direction and quantity of
discrepancy, an occlusal analysis with articulator-
mounted casts is imperative [14].
Therefore, the aim of this study was to assess
the relationship between CR occlusion and
habitual occlusion discrepancy and TMD
symptoms, the spatial planes in which the
discrepancy is found and the correlation between
gender and muscle pain.
2. MATERIALS AND METHODS
The sample consisted of thirty randomly
selected 6th year Dental Medicine students, 14
females and 16 males, aged between 20-30 years,
who agreed to participate in the study. The
research was conducted in the Prosthodontic
Department of the ”Iuliu Haţieganu” University
of Medicine and Pharmacy, Faculty of Dental
Medicine, between January 2018 - June 2018. For
each subject, a two-session examination was
needed for data acquisition. The following data
was collected: anamnesis, clinical examination of
the temporalis, medial and lateral pterygoid
muscles, temporomandibular joint evaluation,

International Journal of Medical Dentistry 59

Smaranda BUDURU, Oana ALMĂŞAN, Rareş BUDURU, Mihai Ioan MIŢARIU, Mădălina MOROŞANU, Mirela FLUERAŞU,
Mariana CONSTANTINIUC

static and dynamic occlusal relationships, and

centric relation manipulation and registration.
Casts of each subject were mounted in centric
relation occlusion by means of an articulator (Bio-
Art). Anamnesis encountered personal data,
presence of tooth, muscle or joint pain, joint noises
and changes in the mandibular movements
(excessive mandible opening, lateral shift during
opening or closing, mouth opening limitation).
Stress levels were evaluated using the Maslach
Burnout Inventory (MBI) in order to assess the
burnout, exhaustion, personal accomplishment, 1.b.
and depersonalization [15]. Values were low for Fig. 1.a. Palpation of the median bundle of the superficial
all subjects, hence this factor was precluded. temporalis muscle; 1.b. Palpation of the masseter muscle
Clinical examination
Clinical examination included temporalis, Dynamic occlusion assumed evaluation of
masseter and medial and lateral pterygoid muscle protrusion and right and left lateral guidance.
evaluation, through: palpation, evaluation of Forty micrometers Bausch articulating paper was
muscle pain, fatigue or muscle trauma. Anterior, used: blue for maximum intercuspation and red for
median and posterior fibers of the temporalis protrusion and lateral guidance (Fig. 2). The type
muscles were symmetrically and simultaneously of lateral guidance and the presence of interferences
palpated with both hands, (Fig. 1a). The muscle or premature contacts were noted. Centric relation
tendon was palpated intraorally. Superior and was evaluated by bimanual guidance, using the
inferior insertions of the masseter muscle were method described by Dawson [17].
also palpated (Fig. 1b). Medial and lateral
pterygoid muscles were evaluated by functional
manipulation. Temporomandibular joint was
examined by inspection, for appreciating the
right-left symmetry. Palpation of the joint
evaluated the lateral and posterior pole. Condyle
excursion on the articular eminence, joint noises
and joint pain were studied. Mandibular
movements were evaluated by maximum opening,
maximum protrusion and maximum lateral (right
and left) movements. Static and dynamic occlusal
relationships were analyzed. Occlusal relationships 2.a.
were evaluated in all three spatial planes - incisors,
canine and first molar areas [16] in habitual
intercuspation occlusion.

2.b.
Fig. 2. Protrusion (a) and lateral guidance (b) tracings
(blue: maximum intercuspation, red: propulsion,
1.a. lateral guidance)

60 Volume 24 • Issue 1 January / March 2020 •

 DISCREPANCY BETWEEN CENTRIC RELATION AND HABITUAL OCCLUSION AND TEMPOROMANDIBULAR
Occlusal contacts in centric relation were
recorded using a forty micrometer Bausch
articulating paper. Mandible shift from maximum
intercuspation to centric relation occlusion was
recorded [18]. When the mandible could not be
guided in centric relation, neuro-muscular
deprogramming was accomplished using a jig of
Moyco wax (Fig. 3), which allowed an accurate
examination of the relationship of the maxilla to
the mandible with relaxed muscles and condyles
placed in a fully seated position [19].
Fig. 3. Jig for muscle deprogramming
Impressions of each subject were achieved using
a high-precision hydrocolloid impression alginate
(Neocolloid, Zhermack). Casts were poured using
fourth class dental stone (Fujirock GC Fuji). Centric
relation was recorded by the power centric method
bite [20]. The relationship of the maxilla to the
cranial base was recorded using the Elite Face Bow
(Bio-Art). Casts were mounted by means of an
articulator (A7Plus, Bio-Art, Fig. 4).
Fig. 4. Casts mounted in centric occlusion
International Journal of Medical Dentistry
DISORDER SYMPTOMS
Measurements in CR and habitual occlusion
were registered using an electronic digital
caliper. In sagittal plane, the distance between
the buccal groove of the mesiobuccal and
distobuccal cusp of the first upper molar and the
buccal groove between the mesiobuccal and
central cusp of the lower first molar was measured
(Fig. 5).
5.a.
5.b.
Fig. 5. Measurements in the sagittal plane (red:
habitual intercuspation [a], black: centric relation [b])
In first molar missing cases, measurements
were performed in second molars. If both the
first and second molars were absent, analysis
was performed on canines, between the middle
of the buccal surfaces of the upper and lower
canines. In transversal plane, the distance
between the upper and lower midlines was
recorded, measuring the midline shift (Fig. 6).
6.a.
61
Smaranda BUDURU, Oana ALMĂŞAN, Rareş BUDURU, Mihai Ioan MIŢARIU, Mădălina MOROŞANU, Mirela FLUERAŞU,
Mariana CONSTANTINIUC

7.b.
Fig. 7. Measurements in the vertical plane (red:
habitual intercuspation [a], black: centric relation [b])
6.b.
Fig. 6. Measurements in the transversal plane (red:
habitual intercuspation [a], black: centric relation [b]) 3. RESULTS

In vertical plane, the distance between the
incisal edge of the upper right central incisor
and the gingival margin of the lower right
central incisor was measured (Fig. 7). In all
three planes, discrepancy was assessed through
the difference between the measured value in
CR occlusion and that in habitual occlusion.
Muscle pain according to gender was
investigated. Data was analyzed using the
Microsoft Excel software. The linear connection
among variables was studied using Pearson’s
bivariate correlation.
7.a.
Muscle pain was found in 57.14% females and
37.5% males. Discrepancy was higher in all
planes in subjects affected with pain. There were
no significant gender differences of discrepancy.
In females with pain, mean transversal
discrepancy was 1.00 mm, mean sagittal
discrepancy was 1.01 mm and mean vertical
discrepancy was 1.19 mm. In females without
pain, mean transversal discrepancy was 0.28
mm, mean sagittal discrepancy was 0.59 mm and
mean vertical discrepancy was 0.62 mm. In males
with pain, mean transversal discrepancy was
0.91 mm, mean sagittal discrepancy was 0.86 mm
and mean vertical discrepancy was 1.43 mm,
respectively. In males without pain, mean
transversal discrepancy was 0.31 mm, mean
sagittal discrepancy was 0.74 mm and mean
vertical discrepancy was 0.52 mm (Table 1).
Median values of discrepancy in all planes were
increased in subjects with pain, inconsequent to
gender, with low standard deviation values for
the transversal plane (Table 2).

Table 1. Mean discrepancy values (mm) according to pain

Pain (number of Transversal Sagittal Vertical

patients) discrepancy (mm) discrepancy (mm) discrepancy (mm)

Gender Present Absent Present Absent Present Absent Present Absent

Females 6 8 0.28 1 0.59 1.01 0.62 1.19

Males 8 6 0.31 0.91 0.74 0.86 0.52 1.43

62 Volume 24 • Issue 1 January / March 2020 •

 DISCREPANCY BETWEEN CENTRIC RELATION AND HABITUAL OCCLUSION AND TEMPOROMANDIBULAR
DISORDER SYMPTOMS

Table 2. Median, arithmetic mean, minimum and maximum discrepancy (mm) according to pain

Arithmetic Standard Correlation

Pain Median Minimum Maximum
mean deviation coefficient
Absent
Transversal 0.26 0.3 0.05 0.63 0.18
16
discrepancy 0.897
(mm) Present
0.92 0.96 0.80 1.36 0.14
14
Absent
Sagittal 0.85 0.69 0.08 1.82 0.48
16
discrepancy 0.249
(mm) Present
0.94 0.95 0.22 2.01 0.53
14
Absent
Vertical 0.36 0.55 0.10 1.63 0.45
16
discrepancy 0.504
(mm) Present
1.15 1.29 0.20 3.25 0.79
14

4. DISCUSSION Studies related to the CR - MIP occlusion

discrepancy using the Mandibular Condyle
Displacement (MCD) tool for measuring the
New relationships between arches have been
condyle rotation have been performed. Very
revealed by the evaluation of the mounted casts
few semi-adaptable articulators are fitted with
in centric relation occlusion using an articulator.
this tool. Discrepancy can be measured using
Decrease in overbite, increase in overjet, midline
any type of semi-adaptable articulator, which
shift, premature contacts in the posterior area
is a useful tool for the clinician in diagnosis
in centric relation have been noticed. Muscle
and treatment planning.
pain was found in a higher percentage in females
Generally, studies report a discrepancy over
but, due to the limited number of participants,
2 mm in vertical and sagittal planes and over 0.5
a conclusion regarding the increased prevalence
mm in transversal plane. In order to compare
in women could not be established. Besides,
our data with the available literature reports,
discrepancy was similar in males and females
[19,21-25] we calculated the percentage of
in all planes. In sagittal plane, the standard
subjects with discrepancy values in vertical and
deviation was high, a low correlation coefficient
sagittal planes higher than 2 mm and intransversal
indicating a zero association, which suggests
plane higher than 0.5 mm (Table 3). In transversal
that the sagittal discrepancy is not related to
plane, we encountered a percentage of 53%,
muscle pain. In vertical plane, although the
which agrees with the results of Cordray et al.
median values were higher in subjects with pain
(57.5%) [19], being lower than those of Costea et
and lower in those without pain, the standard
al. (87.5%) [25] and higher than those of Hidaka
deviation was high, and the correlation
et al. (38,7%) [26]. In vertical plane, the percentage
moderate, suggesting a decreased involvement
was lower than most of the values reported in
of the vertical discrepancy in the onset of pain.
literature: Hidaka et al. - 14% [26], Costea et al. -
The increased median values of the transversal
21.25% [25], Shildkraut et al. - 52% [21] and
discrepancy in subjects with pain, and the
Cordray et al. - 53% [19]. In sagittal plane, the
decreased values in subjects without pain, the
percentage of the present study, of 3%, is similar
low standard deviation and the correlation
to that of Hidaka et al. - 2% [26] and of Costea et
coefficients show a very good association
al. - 7.5% [25], but lower than those of Cordray
between muscle pain and transversal
et al. - 19.6% [19].
discrepancy.

International Journal of Medical Dentistry 63

Smaranda BUDURU, Oana ALMĂŞAN, Rareş BUDURU, Mihai Ioan MIŢARIU, Mădălina MOROŞANU, Mirela FLUERAŞU,
Mariana CONSTANTINIUC
Table 3. Subjects with vertical and sagittal
discrepancy higher than 2 mm and transversal
discrepancy higher than 0.5 mm
Number of Percentage
patients (out of total)
Transversal 16 53.00%
discrepancy
>=0.5mm
Sagittal 1 3.00%
discrepancy
>=2mm
Vertical 2 7.00%
discrepancy
>=2mm
Transversal discrepancy is associated with
muscle pain, as well as in the study reported
by Cordray et al. [20], even if the patients
evaluated by Cordray et al. [19] had been
deprogrammed before registering the centric
occlusion and no gender difference was
correlated with muscle pain.
Roth et al. [24] reported finding of posterior
premature contacts in subjects with discrepancy,
which were also found in our study, even if not
yet investigated.
Our results are similar with those described
by several authors in transversal plane, but
different from those of other authors in vertical
plane. If a higher number of subjects had been
enrolled and deprogrammed, the results would
have been different.
The limitations of the present study are related
to the low number of participants, absence of
muscle deprogramming in some subjects, which
could have led to possible errors in centric
occlusion registration and thus in measurements
of occlusal discrepancy.
5. CONCLUSIONS
Within the limitations of the present study, we
can conclude that discrepancy was found in all
subjects, at least in one spatial plane. Transversal
discrepancy was related to muscle pain. No
gender differences were found between muscle
pain or discrepancy. Future research is needed
64
on a higher number of subjects to study the
condyle discrepancy using the MCD device and
to compare it with occlusal discrepancy. The
clinical relevance of the study is highlighted by
the correlation between muscle pain and
discrepancy. Recording the centric relation
occlusion and mounting of casts by means of an
articulator greatly enhances the treatment
planning process for consistent results in
eliminating muscle pain.
References
1. Jiménez-Silva A, Tobar-Reyes J, Vivanco-Coke S,
Pastén-Castro E, Frugone-Zambra R, Palomino-
Montenegro H. Centric relation-intercuspal
position discrepancy and its relationship with
temporomandibular disorders. A systematic
review. Acta Odontol Scand. 2017;75(7):463-74.
2. Rinchuse DJ, Kandasamy S. Centric relation: a
historical and contemporary orthodontic perspective.
J Am Dent Assoc. 2006; 137(4):494–501.
3. The glossary of prosthodontic terms. J Prosthet Dent.
2005; 94(1):10–92.
4. Lila-Krasniqi ZD, Shala KS, Pustina-Krasniqi T, Bicaj
T, Dula LJ, Guguvčevski L. Differences between
centric relation and maximum intercuspation as
possible cause for development of temporomandibular
disorder analyzed with T-scan III. Eur J Dent. 2015;
9(4):573–9.
5. Haralur SB. Digital evaluation of functional occlusion
parameters and their association with
temporomandibular disorders. J Clin Diagn Res.
2013; 7(8):1772–5.
6. de Sousa ST, de Mello VV, Magalhaes BG, de Assis
Morais MP, Vasconcelos MM, de França Caldas
Junior A, Gomes SG. The role of occlusal factors on
the occurrence of temporomandibular disorders.
Cranio. 2015; 33(3):211–6.
7. Manfredini D, Lombardo L, Siciliani G.
Temporomandibular disorders and dental occlusion.
A systematic review of association studies: end of an
era? J Oral Rehabil. 2017; 44(11):908–23.
8. He SS, Deng X, Wamalwa P, et al. Correlation
between centric relation & maximum
intercuspation discrepancy and
temporomandibular joint dysfunction. Acta
Odontol Scand. 2010;68(6):368–76.
9. Dawson P. Functional occlusion: from TMJ to smile
design. St. Louis: Elsevier Health Sciences; 2006.
10. Bakke M, Moller E, Werdelin LM, et al. Treatment
of severe temporomandibular joint clicking with
botulinum toxin in the lateral pterygoid muscle in
two cases of anterior disc displacement. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2005;
100(6):693–700.
Volume 24 • Issue 1 January / March 2020 •
 DISCREPANCY BETWEEN CENTRIC RELATION AND HABITUAL OCCLUSION AND TEMPOROMANDIBULAR
11. Hodge LC Jr, Mahan PE. A study of mandibular
movement from centric occlusion to maximum
intercuspation. J Prosthet Dent. 1967;18(1):19–30.
12. Rieder CE. The prevalence and magnitude of
mandibular displacement in a survey population. J
Prosthet Dent. 1978; 39(3):324–9.
13. Lim WH, Choi B, Lee JY, Ahn SJ. Dentofacial
characteristics in orthodontic patients with centric
relation-maximum intercuspation discrepancy.
Angle Orthod. 2014; 84(6):939-45.
14. Keshvad A, Winstanley RB. An appraisal of the
literature on centric relation. Part III. J Oral rehabil.
2001;28(1):55–63.
15. Maslach C, Leiter MP. Understanding the burnout
experience: recent research and its implications for
psychiatry. World Psychiatry. 2016; 15(2):103-11.
16. Buduru S. Analiza ocluziei dentare. Clinic versus
articulator. Cluj Napoca: Napoca Star; 2018.
17. Dawson PE. Centric relation. Its effect on occluso-
muscle harmony. Dent Clin North Am. 1979;
23(2):169-80. Effects of CO-CR discrepancy in daily orthodontic
18. Buduru S, Almăşan O. Noţiuni practice de
ocluzologie. 2nd Edition. Cluj-Napoca: Napoca Star;
2010.
19. Cordray FE. Three-dimensional analysis of models
articulated in the seated condylar position from a
International Journal of Medical Dentistry
DISORDER SYMPTOMS
deprogrammed asymptomatic population: a
prospective study. Part 1. Am J Orthod Dentofacial
Orthop. 2006; 129(5):619-30.
20. Schmitt ME, Kulbersh R, Freeland T, Bever K, Pink
FE. Reproducibility of the roth power centric in
determining centric relation. Seminars in orthodontics.
2003; 9(2):102-8.
21. Shildkraut M, Wood DP, Hunter WS. The CR-CO
discrepancy and its effect on cephalometric
measurements. Angle Orthod. 1994; 64(5):333-42.
22. Crawford SD. Condylar axis position, as determined
by the occlusion and measured by the CPI instrument,
and signs and symptoms of temporomandibular
disfunction. Angle Orthod. 1999; 69(2):103-15.
23. Wood DP, Korne PH. Estimated and true hinge axis:
a comparison of condylar displacements. Angle
Orthod. 1992; 62(3):167-75.
24. Roth RH, Rolfs DA. Functional occlusion for the
orthodontist. Part II. J Clin Orthod. 1981; 15(2):100-23.
25. Costea CM, Badea ME, Vasilache S, Mesaroş M.
treatment planning. Clujul Med. 2016; 89(2):279-86.
26. Hidaka O, Adachi S, Takada K. The difference in
condylar position between centric relation and centric
occlusion in pretreatment Japanese orthodontic
patients. Angle Orthod. 2002; 72(4):295–301.
65
Copyright of International Journal of Medical Dentistry is the property of Apollonia
University of Iasi, Medical Dentistry Faculty and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.