Occlusion CLINICAL

Centric relation and increasing the occlusal vertical

dimension: concepts and clinical techniques – part two
Dominic Hassall1

Key points
Long-term deprogrammers and passive muscle The Michigan splint can be a valuable tool when The diagnostic wax-up can be an aesthetic and
contraction can be used to record centric increasing the occlusal vertical dimension and in functional aid when altering the occlusal vertical
relation. temporomandibular cases. dimension.

Abstract
Part one of this article considered the theoretical and clinical aspects of recording centric relation using established
techniques, and presented a range of methods available all with advantages and limitations. This second article will
consider more recent concepts in recording centric relation and practical aspects of increasing the occlusal vertical
dimension.

Introduction separating the posterior teeth. Various forms of

the Lucia jig 1 have developed with proprietary
Long-term deprogrammers/anterior bite planes jigs that can be relined chairside over the
have emerged as a theoretical concept and clinical anterior teeth (Figures 1  and 2) and full
technique to record centric relation. This record chairside acrylic resin fabricated jigs. (Fig. 3).
can then be used to alter the vertical dimension O r i g i na l ly, d e pro g r ammi ng w as
on the semi-adjustable articulator when a recommended for patients that were considered
‘reorganised’ occlusal approach is indicated. ‘difficult’ to bimanually manipulate.6 The
Long-term deprogrammers/anterior bite patient would wear the jig for approximately
Fig. 1 Proprietary Lucia jig (with inclined
planes are disengagement devices that fit 30 minutes before bimanual manipulation. platform and chairside reline)
over the maxillary anterior teeth separating However, it has been questioned if this is
the posterior teeth. There is a long history of sufficient time for full deprogramming and
deprogrammer usage in aiding the recording relaxation of the musculature.7 Consequently,
of centric relation.1,2,3,4 Initially, they were used extended splint deprogramming may be
to form a tripod with the condyles, helping recommended.8,9,10
to locate them in the most anterior-superior
position in the glenoid fossa, and also to Long-term deprogrammers
potentially break muscle memory/engrams
and relax the orofacial musculature. They have Deprogrammers/anterior bite planes have been
also been recommended as a management shown to reduce electromyographic activity
option for temporomandibular disorder.5 in masticatory muscles.11,12,13 Consequently, Fig. 2 Lucia jig in situ
their use has been advocated as a management
The Lucia jig strategy for temporomandibular disorders
and headaches.14,15,16 The American Dental
This was the original occlusal deprogrammer Association approved their use as a possible
and consisted of a flat anterior bite platform management option for headaches and they
are often termed nociceptive trigeminal
1
Restorative, Prosthodontic, Periodontal and Endodontic inhibition (NTI) splints.5
Specialist, Director, Dominic Hassall Training Institute,
Birmingham, UK.
It has been postulated for several decades
Correspondence to: Dominic Hassall that neuromuscular relaxation should form
Email address: [email protected]
an integral part of a physiologically sound and
Refereed Paper. scientific method to record centric relation,17,18
Accepted 20 July 2020
Fig. 3 Chairside fabricated Lucia jig with centric
and the use of longer-term deprogrammers/ recording media applied to the posterior teeth
https://doi.org/10.1038/s41415-020-2593-4
anterior bite planes has become increasingly

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 CLINICAL Occlusion

popular as a method for aiding the recording of

centric relation as this may be physiologically
desirable.19
The concept of ‘freedom in centric’ theorised
that centric relation may be a small biologic
area of temporomandibular joint and disc
position rather than a point as recorded with
bimanual manipulation.20,21
Bimanual manipulation may be considered
to have a number of potential problems, and
there is evidence that deprogramming and
muscle contraction places the condyles into
centric relation.22,23 Consequently, the use of
long-term deprogrammers in conjunction with
patient-determined passive muscle contraction Fig. 4 Deprogrammer with labial bow (Kois-style), pre-adjustment of platform
has emerged as a technique to record centric
relation.

Features of the long-term

deprogrammer

They are generally partial occlusal coverage

maxillary appliances with an anterior bite
plane separating the posterior teeth with
colleted palatal coverage and some form of
tooth-based retention. It is desirable if the
splint can be fabricated easily at low cost and
conveniently fitted by both dentist and patient.
Fig. 5 Long deprogrammer with partial Fig. 6 Long-term deprogrammer with Adams
The Kois-style deprogrammer is based on a
palatal coverage, colleted and retention from clasps on the last standing molars providing
modified Hawley appliance/retainer but with occlusally approaching clasps retention
a full-arch labial bow for retention (Fig. 4).19,24
Alternatively, retention can be obtained via
occlusally approaching clasps (Fig. 5) on the
last-standing molars or Adam’s style clasps
(Fig. 6) on molars, which:
1. Are simpler for the laboratory to construct
2. Allow easier fitting by the patient
and dentist
3. Have higher aesthetic acceptance by the
patient.

Long-term deprogrammers are generally

used for dentate patients. They are not ideal
Fig. 7 Anterior platform, half the mesio-distal width of the central incisors contacting both
for edentulous patients as, while an anterior lower central incisors
platform can be incorporated into an upper
wax rim (or denture), it compromises denture
stability and leads to tipping of the dentures. reduces the chances of tenderness of the lower my experience, I have experienced no adverse
While the anterior bite plane should be incisors due to occlusal trauma. occlusal changes if the appliance is worn for up
narrow enough to achieve point contact These appliances have minimal risk of to 18 hours per day.
or a small linear contact, it should be of inhalation or swallowing, but caution must Long-term deprogrammers provide more
sufficient width to resist fracture. A platform be exercised with the long-term use of partial certainty of deprogramming muscle memory/
approximately half the mesio-distal width of the occlusal coverage appliances as the risk of engrams as they break proprioceptor feedback
upper central incisors resists fracture (Fig. 7), overeruption of unopposed teeth and occlusal from the periodontal ligament for a longer
but this is not possible if the lower incisors are changes is well documented.16,25,26,27 period of time and by eliminating posterior tooth
not well aligned, which necessitates narrowing Partial-coverage appliances are only contact, potentially encouraging more muscle
of the platform. However, contacting more recommended for short-term use and relaxation and thereby allowing the musculature
than one lower incisor can be beneficial as this generally for up to two week’s duration. In to position the condyles into centric relation.

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 Occlusion CLINICAL

3. Where there are maxillary anterior crowns

which are over-contoured palatally.

Using long-term deprogrammers and

passive muscle contraction represents a
physiologically acceptable method of recording
centric relation which is easy to perform
clinically and allows easy checking of the
reproducibility of the centric relation record.
However, clinical studies would be beneficial
to assess the reproducibility of the technique
and compare the centric relation position
obtained with long-term deprogrammers and
Fig. 8 Modified full-coverage Essix retainers with an anterior bite platform on the upper
passive muscle contraction versus operator-
appliance
guided techniques, particularly bimanual
manipulation.
If the patient cannot be deprogrammed or
if joint or muscle symptoms develop, then the
centric relation should not be recorded and
specialist referral may be indicated.
The technique has limitations – for instance:
1. It is a difficult technique to use for
edentulous patients
2. It cannot be used with sore or mobile lower
incisors
3. It is dependent on patient compliance
4. Tolerance to the appliance may be poor in
Fig. 9 Consistent point mark on the anterior platform deep overbite cases.

Anterior bite platforms may also worsen

If more prolonged deprogramming is required possible overeruptions or tiltings. Only if the intracapsular joint symptoms, so a negative
or a long-term splint is indicated, full-coverage position of the mark is consistent (Fig. 9) result to load testing is required before
appliances would be indicated. Upper and lower and there is absence of joint and muscle pain using a long-term deprogrammer.29 If there
Essix-type appliances with an anterior bite plane should centric relation be recorded. are concerns over joint or muscle health,
on the upper appliance are well tolerated (Fig. 8) The centric recording technique is simple, a specialist referral may be indicated or a
and can provide effective management for some as the recording medium is easily introduced longer-term Michigan splint may be indicated,
experiencing temporomandibular disorder.16 onto the occlusal surfaces of the lower which has proved effective in the management
These types of appliances can also be fabricated posterior teeth as the patient closes unaided of the range of symptoms associated with
chairside by adding chairside acrylic to an upper onto the anterior platform. A check is made temporomandibular disorder patients.30
Essix appliance.28 that the mark is in the consistent position. If planning irreversible restorations, then
Theoretically, as the centric relation record fabrication of a Michigan splint is desirable both
Anterior deprogrammer fitting and is patient-determined, this should represent a physiologically and medico-legally. It would be
potential problems position that the muscles and disc condyle area advisable to undertake this stage in the UK for
are comfortable with and should adapt to. at least eight weeks (symptom-free). This is
At fit of the appliance, the anterior platform is My own clinical experience indicates that particularly important if there is a history of (or
adjusted until flat, allowing free anterior tooth there is little clinically detectable difference current) temporomandibular disorder.
movement in all directions and disclusion of between the position of the centric recording
the posterior teeth. mark on the anterior platform when bimanual The Michigan (restorative) splint
The patient taps on the platform which is manipulation is compared to muscle and the functional aesthetic
marked with articulating paper and adjusted contraction after wearing the long-term diagnostic wax-up
until there is a single dot or mesio-distal line deprogrammer. However, the mark is often
and the position of the mark recorded with a more anterior than when using bimanual Originally developed by Ramfjord and Ash,31
photograph. manipulation in certain instances, such as: the splint can be used as a management for
The position of the mark can be reviewed 1. A restricted envelope of function patients with temporomandibular disorder and
and recorded at up to one week and then up 2. Moderate-to-advanced generalised tooth also trialling the occlusal vertical dimension
to one week later. At each appointment, the surface where a class III incisal position increase, centric occlusion and occlusal scheme
occlusion should be closely examined for any has developed before irreversible restorations.

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 CLINICAL Occlusion

Fig. 10 Deteriorating aesthetics of the upper and lower incisor teeth and reduced vertical
dimension due to generalised tooth surface loss Fig. 11 Futar D Fast centric relation record

Fig. 14 Models mounted on Denar Mark II

Fig. 12 Futar D Fast centric relation record Fig. 13 Deprogrammer and centric relation semi-adjustable articulator after removal of
in situ on the lower cast record on the models centric relation record

Fig. 15 Michigan splint constructed at Fig. 17 Diagnostic wax-up and vacuum-

increased vertical dimension Fig. 16 Classic Michigan splint formed matrix in situ

Fig. 19 Pre-treatment occlusal view of upper

Fig. 18 Diagnostic wax-up and vacuum-formed matrix in situ, anterior view arch

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 Occlusion CLINICAL

Fig. 20 Sufficient space created for anterior restorations following the restoration of the
posterior teeth

Fig. 23 Post-treatment occlusal view showing

details of the restoration of the teeth with
indirect restorations and occlusal composites

Fig. 21 Silicone index of diagnostic wax-up Fig. 22 Minimal reduction for e.max
biologically controlling tooth reduction 360-degree veneers

Fig. 25 Completed 360-degree e.max Press

and stain monolithic restorations

and the occlusal vertical dimension

increase and aesthetics would be guided
by the concepts of facially generated tooth
Fig. 24 Completed restorations
position39,40,41 and golden proportions.42,43,44,45
It is well established that, in the majority
It is constructed in the maxilla and is a centric relation, it also trials the new jaw of cases, the occlusal vertical dimension can
permissive splint with point contact of the relationship and centric occlusion. be safely increased,46,47,48 if undertaken in a
occlusal surfaces of the mandibular teeth, If planning large-span cross-arch bridges, controlled manner. The exception is where there
allowing free movement and a degree of the lateral guidance may also be distributed is a history of (or current) temporomandibular
freedom in centric.20 On lateral excursion, to the premolars and potentially the molars. disorder, where long-term wearing of the
canine ramps guide the occlusion, and This may also be the preferred occlusal Michigan splint would be indicated.
on protrusion, there is a platform which scheme if the canines are compromised
discludes the posterior teeth. The splint restoratively or if the restoration is implant- Increasing the occlusal vertical
should be free of non-working side supported. 37,38 If changing the occlusal dimension
interferences. These features of the ‘ideal scheme from an idealised occlusion, these
occlusion’ were established many decades changes can be reflected in the splint. This was done using a long-term deprogrammer,
ago32,33,34 and many of these original features If a diagnostic wax-up is undertaken from Michigan splint and the functional aesthetic
of the idealised occlusion are still valid the centric relation record, this would be diagnostic wax-up (Figures 10, 11, 12, 13, 14,
today. 35,36 As the splint is constructed in undertaken using similar occlusal principles, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25).

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 CLINICAL Occlusion

The patient attended with generalised tooth

surface loss and a long-standing history of
parafunction, temporomandibular disorder
and limited opening. His principle concern
was the poor aesthetics and wear to the
anterior teeth, for which he requested an
aesthetic improvement.
A deprogrammer was constructed and worn
for two weeks before the centric relation record
with Futar D Fast (Optident, Kattenbach,
Germany) which has a rapid set and a high
hardness (Shore-D 43), which facilitates
Fig. 26 Michigan splint in a severe wear case
accurate cast-mounting. A face bow record Fig. 27 Michigan splint cut back from anterior
was undertaken and the casts mounted with teeth and utilised as an occlusal registration
rim. Futar D Fast applied to the splint occlusal
the deprogrammer on the model, enhancing
surfaces for increased interdigitation with
accuracy.
the lower arch
The casts were mounted on the Denar Mark
II semi-adjustable articulator (Prestige Dental,
Whip Mix, USA) for:
1. Occlusal analysis
2. Fabrication of Michigan splint
3. Undertaking of a functional aesthetic
diagnostic wax-up.

The Michigan splint was fabricated on the

Fig. 28 Michigan splint maintaining vertical
articulated casts at an increased occlusal vertical
dimension and centric relation for fabrication
dimension. It was worn for 20  weeks, and of upper crowns
improved the orofacial muscular discomfort
and restricted opening to some degree.
Fig. 29 Fabricated upper crowns
The diagnostic wax-up formed the basis for occlusion and vertical dimension during all the
increasing the occlusal vertical dimension via a restorative stages.
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