Cephalowzetric analysis: Comparisons

between maximum intercuspation and

centric relation
E. H. Williamson, D.D.S., M.S., S. A. Caves, D.M.D., R. J. Edenfield, D.D.S.,
and P. K. Morse, Ph.D.
Augusta, Ga

T he clinical use of cephalometrics has been an adjunct to the practice of

orthodontics since Downs’ first introduced his norms. Since that time, other analyseP7
have sought to establish which skeletal and dental measurements of the individual patient
are not in harmony when compared to the norms. The orthodontist then sets out to correct
the malocclusion by treating the skeletal part which is at fault or modifying other anatomic
parts. The cephalograms used by Downs, Reidel, Ricketts, etc. to establish the ideals
were all made when the patients were maximally intercuspating all their teeth. Even
though their patients may not have had their mandibular condyles properly seated in the
respective fossae, their profiles and occlusions were accepted as normal and, therefore,
constituted standards to which we might compare a patient.
If we are to truly assess the skeletal unit which is at fault and base our treatment
mechanics on this assessment, we must be sure that our records represent the true
anatomic position of these parts relative to one another. A cephalogram taken with the
teeth in maximum intercuspation may give the illusion that the mandible is larger an-
teroposteriorly than it actually is. This situation would occur if the mandible must be
brought down-ward and forward from the glenoid fossa in order to intercuspate the teeth
maximally. Frequently this is the case, particularly in Class II malocclusions, as demon-
strated by Ricketts.s In other words, many Class II’s must “reach” to occlude the teeth.
When the cephalogram is taken with the condyles seated superiorly in the fossa, a prema-
ture contact frequently occurs between maxillary and mandibular molars or premolars,
thus propping the mandible open, increasing the anterior facial height, and placing pogo-
nion in a more retrognathic position. Ideally, we would like the condyles in a retruded,
superior position but with the teeth and pogonion at the original vertical dimension of
maximum intercuspation. The prematurity of deflection prevents us from achieving that.
In order to circumvent this problem, the Centric-Ceph was developed.g This allows
measurements recorded from the Whip-Mix articulator, with the models mounted at
centric relation and adjusted to the vertical dimension of maximum intercuspation, to be
transferred to the lateral head film tracing. A second tracing of the mandible may then be
related to the cranium and maxilla at the centric relation position; that is, with the condyles
seated in their fossae and at the vertical dimension of the original maximum intercuspation
From the Medical College of Georgia School of Dentistry.

672 UUVL-Y+IOI /8/120672+06$00.60/0 0 1978 The C. V. Mosby Co.

Volume 14
Number 6 M~xirnum irltermspution and centric relation 673

Fig. 1. A tracing with the mandible superimposed (shaded area) at centric relation. This illustrates the
anteroposterior difference at pogonion and the vertical difference at the gonial angle. The angular and
millimetric measurements are taken from the Whip-Mix articulator and the Centric-Ceph apparatus.g

(Fig. 1). Cephalometric analysis may then be done routinely to give a true skeletal and
dental representation of our patient.
The purposes of this study are (1) to determine the difference in cephalometric mea-
surements between centric relation and maximum intercuspation of the teeth and (2) to
determine whether any measurement or combination of measurements taken from a
cephalogram made at maximum intercuspation may be used to accurately predict the
deviation from centric relation to maximum intercuspation, thus avoiding the necessity of
articulator mounting.

Methods and materials

Forty-six patients accepted for orthodontic treatment at the Medical College of Geor-
gia School of Dentistry were used as the sample for this investigation. There were
twenty-five female and twenty-one male patients. The mean age was 13.8 years, with a
range of 8.3 to 38.8 years. There were eighteen Angle Class I and twenty-eight Class II
izalocclusions. Lateral cephalometric radiographs were made at a target-to-midsagittal-
plane distance of 60 inches and a midsagittal-plane-to-film distance of 13 cm. These
radiographs were made with the teeth in maximum intercuspation. Maxillary and man-
dibular models were mounted on a Whip-Mix articulator by means of a Quick Mount
face-bow for an arbitrary transfer and an interocclusal record was made with the mandible
in centric relation (that is, with the condyles seated superiorly in the glenoid fossa)‘” and
just prior to first tooth contact. This procedure gives a skeletal relationship of the mandible
to the maxilla without tooth-guided deflections. Following the mounting of the models,
the articulator may then be closed to maximum intercuspation of the teeth, which gen-
 Am. J. Orthod.
674 Wi~~kiF?lWFl tv ~11
December 1918

Table 1. Class I comparison of cephalometric measurements made with teeth in maximum

intercuspation (I) and with the mandible in centric relation (2)

Mean
Variable Mean S.D. DQerence r t* p**

Facial axis (1) 88.78 4.81 0.28 0.992 1.76 0.0%

Facial axis (2) 89.06 5.06
Facial depth (1) 86.61 4.09 0.13 0.990 1.00 0.331
Facial depth (2) 86.47 4.13
Mandibular plane (1) 28.06 6.28 0.14 0.996 1.00 0.33 1
Mandibular plane (2) 27.92 6.49
Convexity (1) 2.11 2.93 0.50 0.987 3.91 0.001
Convexity (2) 2.61 2.62
Lower incisor to APO (mm.) (1) 3.17 3.07 0.45 0.880 1.21 0.244
Lower incisor to APO (mm.) (2) 2.72 2.15
Lower incisor to APO (degrees) (1) 24.56 8.59 0.95 0.969 1.84 0.084
Lower incisor to APO (degrees) (2) 23.61 7.88
Lower facial height (1) 47.75 5.61 1.31 0.982 5.16 0.000
Lower facial height (2) 46.44 5.75

N = 18.
*Correlated t test.
**Two-tailed probability

erally causes one or both condyles to be dislodged from centric relation to a position more
inferior in the glenoid fossa. The technique of transferring the centric relation mea-
surements to the lateral head film radiograph has been described previously.g The
Centric-Ceph mechanism was then used, allowing the centric-relation mandibular position
to be superimposed upon the original tracing of the head film taken with the mandible in
maximum intercuspation. The new mandibular position was then traced relative to the
cranium and maxilla at the original vertical dimension (Fig. 1).
The Ricketts lateral cephalometric analysis was first completed on the head films with
the teeth in maximum intercuspation. Subsequently, the analysis was repeated on the same
head films with the mandible in centric relation. Means, standard deviations, and statistics
relevant to the research questions were calculated.
Results
All measurements labeled (1) were made with the teeth in maximum intercuspation.
All those labeled (2) were made with the condyles in centric relation and at the original
vertical dimension of occlusion with the use of the Centric-Ceph.
For Class I patients (Table I) measurements taken in maximum intercuspation showed
a strong degree of correlation (six of seven measurements correlated at least 0.95) with the
same measurements taken in centric relationship. Although convexity and lower facial
height showed statistically significant differences, the differences were judged not to be of
clinical importance. Hence, for Class I patients it appears safe to depend upon the analysis
based on maximum intercuspation.
Class II patients (Table II) also showed a strong correlation (ranging from 0.788 to
0.972) between the two sets of measurements, but significant differences were found in
four of the seven measurements (convexity, lower incisors to APO in millimeters, lower
Volume 74
Number 6 Mtuimwn inttwusparion and ctwr’ic relntion 675

Table II. Class II comparison of cephalomettic measurements made with teeth in maximum
intercuspation (1) and with the mandible in centric relation (2)

Mean
Variable Mean S.D. Difference r t* p**

Facial axis ( 1) 89.32 4.23 0.25 0.953 0.94 0.355

Facial axis (2) 89.57 4.61
Facial depth (1) 87.11 3.26 0.23 0.960 1.31 0.201
Facial depth (2) 86.88 3.34
Mandibular plane (1) 23.54 5.31 0.47 0.972 1.91 0.066
Mandibular plane (2) 23.01 5.44
Convexity (1) 4.11 2.61 0.78 0.935 3.96 0.000
Convexity (2) 4.89 2.93
Lower incisor to APO (mm.) (1) 1.12 1.42 0.93 0.788 2.66 0.013
Lower incisor to APO (mm.) (2) 0.19 2.71
Lower incisor to APO (degrees) (1) 24.32 4.53 1.96 0.831 2.87 0.008
Lower incisor to APO (degrees) (2) 22.36 6.31
Lower facial height (1) 45.50 4.73 2.09 0.866 4.21 0.000
Lower facial height (2) 43.41 5.23

N = 28.
*Correlated t test.
**Two-tailed probability.

incisors to APO in degrees, lower facial height). More important, the magnitude of the
mean differences, at least for lower incisor to APO (in degrees) and lower facial height,
was judged to be of clinical importance.
The study also sought to determine whether the amount of anterior deflection of the
mandible from centric relation to maximum intercuspation could be predicted from any
combination of the measurements taken from the first Ricketts analysis. Using stepwise
regression analysis, no single predictor or combination of predictors was found to reliably
predict this deflection. The combination of all previous measurements, plus dummy
variables indicating the type of bite, produced a maximum multiple r of 0.369 with ten
predictors in the equation; the probability was 0.840 that a multiple correlation this strong
or stronger could arise by chance, given this many variables and a sample of forty-six
cases.
It was hypothesized that deep-bite and open-bite cases would demonstrate more an-
terior deflection than cases of normal overbite. In order to test this hypothesis, deep-bites
were defined as those in which 50 percent or more of the mandibular incisor was covered
by the maxillary incisor. Open-bites were those which had no maxillary and mandibular
incisor overbite or no contact of the lower incisors with palatal soft tissue. The mean
difference was in the predicted direction but small (0.24 mm.) and not significant
(t = 0.84, P = 0.20). It was also hypothesized that Class II malocclusions would show
more anterior slide than Class I. Again, the difference between means was in the predicted
direction but small (0.35 mm.) and nonsignificant (t = 1.24, P = 0.11). The range of
deflection for the twenty-eight Class II cases was 0 to 4 mm., and five had an anterior slide
of 2.5 mm. or greater. The range for Class I cases was 0 to 2.5 mm., and only two of
eighteen subjects displayed an anterior slide of 1.5 mm. or more.
By means of the Centric-Ceph, it is possible to measure the amount of vertical
 Am. J. Orthod.
December 1978

difference of the gonial angle between maximum intercuspation and centric relation. For
Class II malocclusions, the genial angle was 1.37 mm. (S.D. 2.26) more superior at
centric relation. The range was - 2 to + 5 mm. with seven cases of twenty-eight seating
3 mm. or greater more superior in centric relation. For Class I malocclusions, the genial
angle was 1.02 mm. (S.D. 1.23) more superior in centric relation. The range was 0 to 2.5
mm. The difference between Class I and Class II was not significant (t = 0.94, P > 0.1).

Discussion
It becomes obvious from this study that there are measurable differences in Ricketts’
cephalometric analysis between the centric-relation position of the mandible and maxi-
mum intercuspation, especially for Class II patients. The differences between means
appear relatively small from a cephalometric diagnostic point of view (Tables I and II). It
has also been demonstrated that no single cephalometric measurement or combination of
measurements made with the mandible in maximum intercuspation reliably predicts the
anterior movement of the mandible from centric relation to maximum intercuspation. The
operator must therefore rely upon articulator-mounted models to obtain this information.
Even though mean differences were not great, it should be noted that some patients
showed relatively large anterior movement; that is, Class II malocclusions varied from 0
to 4 mm., with five cases having 2.5 mm. or greater slide horizontally. It is interesting that
the mean amount of anterior slide from centric relation to maximum intercuspation closely
coincides with the average shown by PosseIt” and Ingervall”( 1 mm.), while the present
study showed Class II to be 1.2 mm. and Class I to be 0.7 mm. Another point of interest
was the amount of superior movement of the gonial angle from maximum intercuspation
to centric relation. This phenomenon has been stressed frequently in other studies.i3* ” In
this investigation, although there was no statistically significant difference between Class I
and Class II, seven of twenty-eight Class II cases seated 3 mm. or more superiorly with a
range of 0 to 5 mm., while the Class I range was 0 to 2.5 mm. Certainly, this is a clinical
point of interest for diagnostic purposes, but it is demonstrable only by means of ar-
ticulator mountings.
The information from this study may be applied clinically in the following manner.
First, cephalometric analysis and evaluation should continue to be made from radiographs
taken with the teeth in maximum intercuspation. This is confirmed by the high coefficients
of correlation and the relatively small differences between the cephalometric mea-
surements taken in centric relation and maximum intercuspation (Tables I and II), particu-
larly in Class I. Second, all cases should be assessed clinically with the mandible in
centric relation prior to treatment. It is our opinion that al1 Class II cases should be
articulated. This judgment is based upon the fact that five of twenty-eight Class II subjects
had a horizontal slide of 2.5 mm. or greater and four of seven cephalometric mea-
surements in Class II patients revealed significant differences (P < 0.02) between the two
positions. Class II patients with large anteroposterior discrepancies frequently exhibit
buccolingual disharmony between the mandibular and maxillary teeth. When the articu-
lated models are critically assessed with the mandible in centric relation, inordinate
mandibular growth must occur in order to achieve future coupling of anterior teeth, which
allows for eccentric disclusion of the posterior teeth. Even with extraction of maxillary
first premolars, excessive lingual movement of maxillary canines and buccal expansion of
mandibular canines become necessary. This creates very dubious stability in retention.”
Volrrme 74
Number 6

Such patients may require more extreme treatment (that is, orthognathic surgery). It is far
better to diagnose these possibilities in advance of treatment and discuss them with parents
and patient.

Summary and conclusions

Cephalometric analyses were made of forty-six preorthodontic patients with the man-
dibular teeth in maximum intercuspation. A Centric-Ceph was used and the analysis was
repeated on these patients with the mandible in centric relation. The following conclusions
are drawn:
1. No clinically useful prediction may be made from cephalometric radiographs con-
cerning the amount of mandibular deflection from centric relation to maximum intercus-
pation of teeth.
2. There are differences in cephalometric measurements with the mandible in the two
different positions. However, with the exception of a few cases, the differences are slight.
3. The individual cases that have the largest discrepancies tend to be Class II maloc-
clusion cases. The orthodontist should be aware of those cases and be prepared to articu-
late them for diagnosis.

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