CENTRIC

RELATION
MASTICATORY MUSCULATURE

• When bone and muscle war, muscle never loses - Harry Sicher

• When teeth and muscle war, muscle never loses – Peter E. Dawson

• Muscle is the dominant determinant of both the horizontal and vertical position

of the teeth.
COORDINATED MUSCLE ACTIVITY

Coordinated muscle function Coordinated muscle function Coordinated muscle function at

during jaw closure during jaw opening maximum intercuspation and
clenching
MASTICATORY MUSCLES

• Positioner muscles (Responsible for horizontal movements from CR)

• The inferior lateral pterygoid muscles pull the condyle down and forward

• Elevator muscles (Pull the mandible back and up)

• Superior lateral pterygoid helps to position the disc with the condyle during function
Disharmony between occlusion Incoordinated muscle function
and TMJ
MECHANISM OF DISC DERANGEMENT
Stretched

Position of the attachment changes

Torn
CRITERIA FOR CENTRIC RELATION

• The complete release of the inferior lateral pterygoid muscles

• Proper alignment of the disk on the condyle. During jaw closure with intact TMJs, the condyle

disk assemblies are pulled up the eminentiae by a triad of strong elevator muscles
• Refers to a both position and condition of the condyle disk assemblies

• The condyles can freely rotate on a fixed axis at this position up to about 20mm of jaw

opening without moving out of the fully seated position in their respective fossa

• The mandible can be in CR even when the teeth are separated or even if there are no teeth in

either jaw
MISCONCEPTIONS OF CR
• Centric relation is a fixed axial position of the condyles. This does not mean that the mandible is
restricted to centric relation during function. The rotating condyles are free to move down and up the
eminence to and from centric relation, permitting the jaw to open or close at any position from centric
relation to most protruded

• Centric relation should not be confused with centric occlusion, an obsolete term that has been replaced
with maximum intercuspation. Centric relation refers to the fully seated condylar position regardless of
how the teeth fit.

• Centric relation is not about teeth. It is about the position of the condyles. The position of the condyles
determines the relationship of the mandible to the maxilla, even when no teeth are present The
edentulous mandible is in centric relation if the condyle-disk assemblies are completely seated.
• Centric relation is not just a convenience position that is used because it is repeatable. It is the
universally accepted jaw position because it is physiologically and biomechanically correct and
is the only jaw posi- tion that permits an interference-free occlusion.

• The fact that the definition of centric relation has changed from its original definition of “most
retruded” does not make either the newer “uppermost” definition or the concept of centricity
obsolete. The current definition is consistent with the position described and advocated for more
than 30 years. What has changed is a better understanding of the anatomy of the TMJ, and in
particular the importance of disk alignment and the medial poles of the condyles. We learned that
the temporomandibular ligament is not a factor in centric relation as was originally believed.
However, the concept of “uppermost” instead of “rearmost” has not changed.
DISSECTING THE DEFINITION

• The relationship of the mandible to the maxilla

• Properly aligned Condyle – Disk Assemblies

• Against the eminentiae

• Irrespective of tooth position or vertical dimension

• Most superior position

THE IMPORTANCE OF INFERIOR LATERAL PTERYGOID
MUSCLE

• Positioner muscle – Lateral Pterygoid

• Sole responsibility for positioning the mandible to align with maximum inter-occlusal contact whenever CR is
not coincident with MI

• Lateral pterygoid is thus put into antagonistic isometric contraction in resistance to the strong elevator muscles
every time the jaw closes

• Measurements as small as 0.1mm of displacement leads to recruiting single motor neurons within the lateral
pterygoid muscle - Murray et al

• Significant portion of the fibres are anaerobic and this fast acting and fatigue susceptible – Mao et al
SIGNIFICANCE OF THE TMJ JOINT
SOCKET DESIGN
THE MANDIBLE IS THUS IN CR IF THE
5 CRITERIA ARE FULFILLED
• The disk is properly aligned on both condyles.
• The condyle-disk assemblies are at the highest point possible against the posterior slopes of the
eminentiae.
• The medial pole of each condyle-disk assembly is braced by bone.
• The inferior lateral pterygoid muscles have released contraction and are passive.
• The TMJs can accept firm compressive loading with no sign of tenderness or tension.
 EVOLUTION OF CR
1) The most retruded relation of the mandible to the maxillae when the condyles are in the most posterior unstrained
position in the glenoid fossae from which lateral movement can be made at any given degree of jaw separation (GPT-
1)
2) the most retruded physiologic relation of the mandible to the maxillae to and from which the individual can make
lateral movements. It is a condition that can exist at various degrees of jaw separation. It occurs around the terminal
hinge axis (GPT-3)
3) the maxillomandibular relationship in which the condyles articulate with the thinnest avascular portion of their
respective disks with the complex in the anterior– superior position against the shapes of the articular emi- nencies.
This position is independent of tooth contact. This position is clinically discernible when the mandible is directed
superior and anteriorly. It is restricted to a purely rotary movement about the transverse horizontal axis (GPT-5)
• 4) The most posterior relation of the lower to the upper jaw from which lateral movements can be
made at a given vertical dimension (Boucher)

• 5) A maxilla to mandible relationship in which the condyles and disks are thought to be in the
midmost, uppermost position. The position has been difficult to define anatomically but is determined
clinically by assessing when the jaw can hinge on a fixed terminal axis (up to 25 mm). It is a clinically
determined relationship of the mandible to the maxilla when the condyle disk assemblies are
positioned in their most superior position in the mandibular fossae and against the distal slope of the
articular eminence (Ash)
• 6) The relation of the mandible to the maxillae when the condyles are in the uppermost and rearmost position in the

glenoid fossae. This position may not be able to be recorded in the presence of dysfunction of the masticatory system

• 7) A clinically determined position of the mandible placing both condyles into their anterior uppermost position. This

can be determined in patients without pain or derangement in the TMJ (Ramsfjord).

• 8) McCollum and Stuart [1955] proposed a definition for CR in which the condyles are in a ‘rearmost, uppermost and

midmost (RUM) position in the glenoid fossae’

 DEFINITION

• A maxillomandibular relationship, independent of tooth contact, in which the condyles

articulate in the anterior–superior position against the posterior slopes of the articular
eminences, in this position the mandible is restricted to purely rotary movement, from this
unstrained, physiologic, maxillomandibular relationship, the patient can make vertical, lateral
and prostrusive movements; it is a clinically useful, repeatable reference position (GPT 9)
ADAPTED CENTRIC
POSTURE
• When TMJs under go deformation, disease, trauma and
remodeling they may still function with complete comfort
and apparent normalcy
• When occlusal wear occurs and leads to TMJ
deformation, the progression from a healthy to a deformed
TMJ is progressive and can occur in pain in the early
stages
• Example : A painful compression of restrodiskal tissue
followed by complete disk displacement → The
retrosdiskal tissue converts into a fibrous pseudo – disk →
Alternatively, the disk may break down and perforate
bringing about a bone to bone contact
ADAPTED CENTRIC POSITION

• The condyles are comfortably seated at the highest point against the eminentiae.
• The medial pole of each condyle is braced by bone. (The disk may be partially interposed.)
• The inferior lateral pterygoid muscles have released contraction and are passive.
• The condyle-to-fossa relationship is manageably stable.
• Load testing produces no sign of tension or tenderness in either TMJ.
DETERMINING CENTRIC RELATION
D AW S O N ’ S B I M A N U A L M A N I P U L A T I O N
 STEPS
• Recline the patient all the way back

• Stabilize the head

• After the head is stabilized, lift the patients chin again to slightly stretch
the neck

• Gently position the four fingers of each hand on the lower border of the
mandible

• Bring the thumbs together to form a C with each hand

• With a very gentle touch, manipulate the jaw so it slowly hinges open and
closed

• After the mandible feels like its hinging freely and the condyles seem to be
fully seated up in their fossa, most clinicians assume that the mandible is
in centric relation
 LOAD TESTING
• It is a concept of applying mild – firm pressure upwards

• It is done once centric relation has been established

• It is done to verify if centric relation thus established is correct

• It helps distinguish between occluso – muscular and TMD issues (Although not at the
outset)

• Dawson suggests that a CR record must never be accepted without load testing

• Possible reasons for pain during load testing are a) Intracapsular disorder b) muscle
bracing c) misaligned disk
ANTERIOR BITE STOPS

• Permit separation of all posterior teeth

• Condyles are free to move horizontally and

vertically to their uppermost seated positions

• All these required a bite material once the CR has

been determined

• It shuts down the inferior lateral pterygoid activity

as well as 2/3rds of the masseter muscles activity
DIRECTLY FABRICATED
ANTERIOR DEPROGRAMMING
DEVICE

• Self cure acrylic is moulded on the upper incisors

• During dough stage, the mandible is manipulated to CR

• Jaw is closed so that the lower incisors indent the soft

acrylic, but is stopped short of posterior contact

• Once it cures, the surface is ground flat, to allow full

horizontal movement of the mandible

• A bite material is used to record the posterior teeth

PANKEY JIG
• Dr. Keith Thornton
• Cost effective and easy to use
• It is fixed on the upper incisors
such that the lower incisors
contact a flat surface allowing
free movement
B E S T B I T E A P P L I A N CE
• Exactly the same as the Panket
jig
• A kit is available with an
injection material for stabilizing
the appliance
LUCIA JIG

• First one to employ an anterior stop

• Jig was originally slanted to direct the
condyles distally (Based on early
misconceptions, wherein centric relation
was the most retruded)
• It was modified by Dr. Peter Neff to
permit upward condylar movement
without a distalizing effect
NOCICEPTIVE • Exactly the same as an anterior bite stop device

TRIGEMINAL • It has been advertised as an appliance for treating migraine

headaches and other facial problems
INHIBITION • In the event of an intracapsular disorder, the usage of such devices
will not reduce the pain, nor will it help record the correct centric
relation
• In fact, it might even increase the discomfort by overloading
LEAF GAUGE

• Dr. Hart Long

• Contains flexible mylar strips that may be added or
removed to create the necessary separation to push the
mandible back to CR
• It consists of a slick surface upon which the mandible
can easily move horizontally.
DISADVANTAGES OF ANTERIOR BITE
STOPS
• During equilibration procedures, you cannot mark occlusal interferences with an anterior bite
stop in place. Bilateral manipulation ensures correct condylar position during closure all the way
to tooth contact.

• Even with an anterior bite stop in place, load testing to verify centric relation is the only sure
way to ensure accuracy.

• Load testing can be done in increments starting with gentle loading first to rule out intracapsular
disorders before firm loading by elevator muscles when an anterior bite stop is in place.
• Bilateral manipulation with load testing has been proven to be accurate without the need for
added appliances or extra steps. However, if combining bilateral manipulation with an anterior
deprogrammer appliance is helpful to the operator, it should be used.

• For accuracy with the highest level of efficiency, you will find that it is worth the time and
effort to become proficient in bilateral manipulation. It is a skill that will be used on every
patient.
RECORDING CENTRIC RELATION

• The bite record must not cause any movement of teeth or displacement of soft tissue.

• It must be possible to verify the accuracy of the interocclusal record in the mouth.

• The bite record must fit the casts as accurately as it fits the mouth.

• It must be possible to verify the accuracy of the bite record on the casts.

• The bite record must not distort during storage or transportation to the laboratory.
WAX BITE RECORD

• DELAR WAX
• The wax is flamed to produce a shine
• Maxillary Premolars have to make a definitive
indentation
• While warm, the wax is is removed and trimmed
• It is placed back in the mouth and mandible is eased into
CR position
• Must NOT touch the palatal tissue
ANTERIOR STOP
TECHNIQUES
• Anterior stop refers to a contact in the incisor area
• Should be thin enough so that the first point of tooth
contact barely misses
 ROTH’S POWER BITE
• Requires the precise location of CR before the closing
power from the elevator muscles is applied.
• Bite material ( softened compound or wax wafer ) is
used to make a bite record between the upper and lower
anterior teeth
• Patient is made to put their tongue to the roof of their
mouth and relax the lower jaw, while the operator
guides the bite backwards
• Closure must be stopped short of any posterior tooth
contact
• The wax wafer Is removed and softened replaced.
Softened wax is placed in the posterior teeth until the
anterior teeth contact the previously registered bite
• The patient is then asked to clench tightly to allow the
condyle to seat in CR
 ANTERIOR INDEX FOR CR
• Used along with Bimanual manipulation

• A little ball of red compound is adapted over the upper anteriors,

extending it lingually. It is moulded over the incisal edge to provide
stability

• The mandible is manipulated bimanually the patient is made to close

over the softened compound until the posterior teeth just barely miss
contacting

• Once the index is verified, the bite registration material is mixed and
placed on the lower teeth, and the patient closes into the stop
position and holds the jaws together with firm pressure
• The bite once set, is removed and trimmed back to the tips of the lower buccal cusps and the
central grooves of the upper teeth

• The bite record is replaced in the mouth and checked for accuracy once again
 EDENTULOUS
RIDGES
• Premade wax base is adapted
onto the cast (with provision for
the future putty material)
• It is placed in the mouth, and
lower jaw is manipulated into4
CR position
• The patient is asked to make
slight indentations onto the wax
• Putty silicone is added to the
preformed base, and patient is
made to close into the
indentations
 EVIDENCE TO INDICATE SUPERIORITY IN CR
REGISTRATION METHOD

• Condylar positions generated by five centric relation recording techniques - Adam L. Swenson, Larry J.
Oesterle*, W. Craig Shellhart, Sheldon M. Newman and Gerald Minick

• Roth Power Bite, Tongue Tip to Soft Palate, Leaf Gauge, Chin Point Guidance, and Bimanual Manipulation.

• All methods of CR registration resulted in a very small range of variation indicating a high degree of intra-
technique repeatability.

• However, location within the condylar fossa varied between the different techniques with the Roth Power Bite
and Leaf Gauge Techniques positioning condyles slightly more anterior-superior than other techniques studied.
 CR – WHERE ARE WE NOW?
A N E V I D E N C E - B A S E D E VA L U AT I O N O F T H E C O N C E P T O F C E N T R I C R E L AT I O N I N T H E 2 1 S T C E N T U R Y
S A N J I VA N K A N D A S A M Y, B D S C , B S C D E N T, D O C C L I N D E N T, M O R T H R C S , F R A C D S , F D S R C S 1 / C H A R L E S S .
GREENE, BS, DDS2/ ALES OBREZ, DMD, PHD3

• A small ball shaped condyle articulating with a shallow fossa – Primary teeth have occlusal contacts that determines
condylar seating - Permanent teeth erupt – condyle – fossa relationship changes contiunously until growth and
development continuous.

• Tooth wear occurs throughout life and results in a constant remodelling of the TMJ complex, and the maxillomandibular
position is always anterior to any definition of CR position

• Alexander et al ( 25 years ago) conducted MRI studies and showed the positions assumed are not close to what clinicians
refer to ( that recorded by manual methods)

• Although ROTH centric bite was the accepted accurate method of registration, it has been questioned clinically in a
study utilizing MRI
• Kandasamy et al concluded that positions of MI, CR and retruded CR could not be consistently
measured by the same clinicians.

• Studies as early as 1960s found that entire dentitions when re-establised to the CR position,
found that the subjects continued to close and function in more anterior positions.

• Problems associated with CR transfer and mounting

 CONTEMPORARY CLINICAL APPLICATIONS
FOR CR
• Complete dentures
• Full mouth reconstructions
• Orthodontists use this as a target zone for completing their cases
• Stable jaw relationships for orthognathic surgeries
• The subject must not have a dual bite
• Based on current evidence, it is wise to use the patient’s MI position as a reasonable
physiological guide when restoring and replacing teeth rather than deliberately altering the
condyle fossa relationship.
THANKYOU!