Section 10 - Centric Relation

Handout
Abstracts
001. Atwood, D.A. A critique of research of the posterior limit of the mandibular position. J
rosthet Dent !0"!1-#$, 1%$&.
00!. 'oss, '. (. A functional cranial anal)sis of centric relation. DC*A 1%"+#1-++!, 1%,-.
00#. (e.), . /. Clinical implications of mandibular repositionin0 and the concept of an alterable
centric relation. DC*A 1%"-+#--,0, 1%,-.
00+. Jan1elson, 2. *euromuscular aspects of occlusion" 3ffect of occlusal position on the
ph)siolo0) and d)sfunction of the mandibular musculature. DC*A !#"1-,-1$&, 1%,%.
00-. Dawson, . 3. 4ptimum 5'J cond)lar position in clinical practice. 6nt J erio Rest Dent
#"11, 1%&-.
00$. 7in0er), R. /. A re.iew of some problems associated with centric relation. J rosthet Dent
!"#0,-#1%, 1%-!.
00,. 8ood, 9.8. Centric relation and the treatment position in rehabilitatin0 occlusions" A
ph)siolo0ic approach. art 6" De.elopin0 optimum mandibular posture. J rosthet Dent -%"$+,-
$-1, 1%&&.
00&. /ic1e), J. A. Centric relation - A must for complete dentures. DC*A *o. 1%$+"-&,-$00.
00%. 9lic1man, 6., et al. 5elemetric comparisons of centric relation and centric occlusion
reconstructions. J rosthet Dent #1"-!,--#$, 1%,+.
010. Shafa0h, 6., et al. Diurnal .ariance of centric relation position. J rosthet Dent #+"-,+--&!,
1%,-.
011. 9ilboe, D. R. Centric relation as the treatment position. J rosthet Dent -0"$&--$&%, 1%&#.
01!. 8illiamson, 3. /., et al. Centric relation" A comparison of muscle determined position and
operator 0uidance. Am J 4rtho ,,"1##-1+-, 1%&0. J rosthet Dent #%"-$1--$+, 1%,&.
01#. Serrano, . 5., *icholls, J. 6. and :uodelis, R. A. Centric relation chan0e durin0 therap) with
correcti.e occlusal prostheses. J rosthet Dent -1"%,-10-, 1%&+.
01+. (ucia, ;. 0. Centric relation - theor) and practice. J rosthet Dent 10"&+%-&-$, 1%$0.
01-. 9uichet, *. <. 2iolo0ical laws 0o.ernin0 functions of muscles that mo.e the mandible. a.
art 6" 4cclusal pro0rammin0. J rosthet Dent #,"$+&-$-$, 1%,,. b. art 66" Cond)lar position. J
rosthet Dent #&"#--+1, 1%,,.
c. art 666" Speed of closure - manipulation of the mandible. J rosthet Dent #&"1,+-1,%, 1%,,. d.
art 6;"
De0ree of =aw separation and potential for ma>imum =aw separation. J rosthet Dent #&"#01-#10,
1%,,.
Section 10: Centric Relation
(Handout)
Definitions:
Centric Relation ?CR@" the ma>illomandibular relation in which the cond)les articulate with the
thinnest a.ascular portion of their respecti.e discs with the comple> in the anterior-superior
position a0ainst the shapes of the articular eminences. 5his position is independent of tooth
contact. 5his position is clinicall) discernible when the mandible is directed superiorl) and
anteriorl). 6t is restricted to a purel) rotar) mo.ement about the trans.erse horiAontal a>is.
Depro0rammer" .arious t)pes of de.ices or materials used to alter the propriocepti.e mechanism
durin0 mandibular closure.
'a>imum 6ntercuspation ?'6@" the complete intercuspation of the opposin0 teeth independent of
cond)lar position.
Anatomy influence on Centric Relation:
1. Atwood states that there are two basic concepts of CR.
a. anatomic concept - the most posterior border position is established b) li0aments.
b. pathoph)siolo0ic concept - the most posterior unrestrained =aw relationship ?not a border
position@
established b) muscle action.
5he posterior limit of the mandible is established b) structures anterior and lateral to the
cond)les ?lateral pter)0oid and temporomandibular li0ament@ rather than posterior to them. 5he
temporomandibular li0aments contain propriocepti.e ner.e endin0s, susceptible to stretchin0,
leadin0 to inhibition of the retrusi.e muscles ?temporalis and di0astrics@, and stimulation of the
protrusi.e anta0onist muscles ?lateral pter)0oids@.
5he term Bunrestrained B relates to no undo force causin0 distortion of the tissues.
Does reproducibilit) assure correctnessC DDDDDDDDD
!. 'oss stated that"
a. CR is a nonfunctional position that is not habitual or common.
b. Are the functional surfaces of the 5'J capable of adaptation o.er lon0 periods of timeC
DDDDDDD
c. 8hen would these chan0es occurC DDDDDDDDDDD
d. 5he d)namicall) fluctuant state of the neuromuscular apparatus ma1es it reasonabl) certain
that
.ariation in CR position can e>ist. 3>. ain caused b) a hi0h restoration.
e. As mandibular function be0ins, and muscles contract, the functionin0 =oint surfaces are
brou0ht
into a compressi.e articulation and the cond)lar heads are not in CR.
#. 8hat is (e.)Es d)namic concept of centric relationC
a. A quasi-fi>ed position of temporar) duration which e>ists in a state of equilibrium
established b)
the neuromusculature and li0aments.
b. Does this mean that the 5'J and musculature can adapt b) remodelin0 to the newl)
acquired
intercuspationC
c. Accordin0 to (e.), does this mean that a fi>ed retruded positional concept can lead to
unnecessar)
treatmentC
Dawson stated that in CR"
a. roper ali0nment of the cond)le dis1 assembl) is required and the cond)les should be
a0ainst the
eminentia.
b. 5he medial pole pla)s the predominant stop of upward mo.ement of the cond)le.
c. 5he muscles surroundin0 the =oint pull the cond)le dis1 assembl) firml) a0ainst the
eminentia.
d. 3le.ator muscles ?temporalis, masseter, and medial pter)0oid@ pull superiorl).
e. 5he medial pter)0oid pulls the medial pole of the cond)le into the buttressed part of the
0lenoid
fossa. 5he medial pole of the cond)le braced a0ainst the 0lenoid fossa can ha.e no posterior
mo.ement without mo.in0 inferiorl).
f. 5he anterior pole of the cond)le rests a0ainst the eminence and pre.ents forward mo.ement.
0. 5he medial pole of the cond)le ?superior-anterior@ seated in CR can ma1e a rotar)
mo.ement.
5he lateral pole of the cond)le can translate durin0 openin0 and closin0 of the mandible
while in
CR due to an0ulation. 5his anatom) allows occlusal relationship records to be ta1en at
.ar)in0
.ertical dimensions of occlusion as lon0 as the correct horiAontal a>es are recorded.
h. (ateral pter)0oid muscles resist the ele.ator muscles and de.iate the mandible to a.oid
occlusal
interferenceEs.
i. Centric relation is a functional position and relates to the muscle harmon) of the patient.
=. 4cclusal interferenceEs to the uppermost centric relation position mean that the lateral
pter)0oids
must de.iate the mandible to conform to the ma>imum occlusal position and the) cannot
de.iate
to that position without ser.in0 as a holdin0 muscle a0ainst the ele.ator muscles. 5his can
pro0ress
into a clenchin0 pattern, and incoordinated musculature.
1. 2ilateral manipulation is the method preferred to determine optimum 5'J cond)le position.
8here are the fin0ers placed for this methodC DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
-. Accordin0 to 9ilboe, is it possible to place the cond)le in a position so posterior that the
cond)le-dis1 assembl) is no lon0er in contact with the eminenceC DDDDD
6f an internal deran0ement e>ists, the most posterior position could be patholo0ic. 8ith an
anteriorl) displaced dis1, the cond)lar articular surface bears on the posterior band of the intra-
articular tissue.
6f restored in this position, can an iatro0enicall) induced deran0ement of the 5'J occurC DDDDD
Does reproducabilit) impl) desirabilit)C DDDDDDDDDD
Restorati.e ser.ices should be postponed until CR has been established and confirmed b) the
absence of s)mptoms.
Centric Relation, Why is it imortant!
CR is a bone to bone position and '6 is a tooth to tooth position.
CR is the onl) clinicall) repeatable ?.erifiable@ =aw relation. 6t is the lo0ical position to fabricate
a prosthesis.
CR and '6 are coincidental in onl) 10F of the population. 5he discrepancies between
CR and '6 can be obser.ed on articulated stud) casts.
8hen is it neededC An accurate CR recordin0 should be made to reduce time spent ma1in0
intraoral ad=ustments at deli.er). Applicable situations include"
a. '6 not clearl) defined due to restored dentition.
b. Chan0in0 ;D4
c. 4cclusal scheme - 0roup function rather than mutual protection.
d. 5'J disorder patients with occlusal discrepancies as part of the etiolo0) of the 5'D.
e. An0lesE class 66 patients requirin0 freedom to mo.e from CR to a pseudo - class 6
?protrusi.e@
position.
f. 8hen the number of artificial teeth out number the natural teeth.
Systems for recordin" Centric Relation:
Static Recordin0 ? interocclusal chec1 bite@ - teeth or supportin0 tissues as predominant factors.
4ldest and most commonl) used method used toda). CR recordin0 should alwa)s be .erified
a0ainst a second recordin0. 5here should be no tooth contact throu0h the CR records. 6f contact
occurs, undetected mandibular translation ma) occur due to deflecti.e contacts or neuromuscular
a.oidance mechanism. 8hen a slide to '6 is present, the first contacts in CR are usuall) the
most posterior teeth, and the molars can act as a fulcrum to cause the cond)les to mo.e down
and bac1ward initiall) and then forward as the teeth slide into '6.
9raphic Recordin0 - intraoral or e>traoral 9othic arch tracin0s.
h)siolo0ical G <unctional Recordin0 - usuall) recorded on wa> rims or wa> cones durin0
un0uided G unassisted patient mo.ement.
Cephalometric Recordin0 - cephalometric radio0raph) to determine optimal position of the
cond)les. 6mpractical and seldom used.
Dero"rammer: Depro0rammin0 de.ices are used to eliminate muscle en0rams, pre.ent the
acti.ation of the neuromuscular a.oidance mechanism, and allow the mandible to more easil)
achie.e the CR position. 8hile the concept of usin0 depro0rammin0 de.ices to record CR is
widel) accepted, contro.ers) and .ariation in technique abound. Current literature tends toward
a0reement that depro0rammin0 ta1es about #0 minutes. 'ore time ?se.eral hours or o.erni0ht@
does not pro.ide benefit. Some of the ma=or techniques include"
1. 2ite on cotton roles" used with chin point 0uidance. 5his was the norm when the definition of
CR was the most retruded position.
!. (ucia =i0" a Durala) =i0 was made indirectl) and fitted durin0 depro0rammin0, ad=usted with a
sli0ht incline until a 0othic arch tracin0 was demonstrated with articulatin0 paper. 5he CR record
is made with a hard material on a wa> wafer and the patient closed firml) onto the =i0. 5he
criticism of this technique toda) re.ol.es around the incline of the =i0 and the choice of wa> to
ma1e the record. 3lastomeric materials were not a.ailable.
#. (eaf 0au0e" this de.ice was .er) popular in the se.enties and ei0hties. 5he patient closed into
a thic1 0au0e and lea.es were remo.ed until the teeth were minimall) separated in what was
assumed to be CR. 5he record was made with the leaf 0au0e in place. Drawbac1s included the
incline of the leaf 0au0e ma) force the cond)les posterior. 8illiamson recommended less bitin0
force to allow the ph)siolo0ic placement of the cond)les in the 0lenoid fossa.
+. Anterior flat plane" essentiall) a (ucia =i0, but without an) inclines. Hsed in the power centric
recordin0.
Recordin" techni#ues:
Chin-point 0uidance" not recommended due to the posterior displacement and stress on the
bilaminar Aone.
2imanual technique ?Dawson@" patient is depro0rammed usin0 an anterior de.ice or leaf 0au0e.
<in0ers are at ri0ht an0les with upward pressure, thumbs on chin with downward pressure.
'anipulate into pure hin0e mo.ement ?romancin0 the mandible@. 5his technique is accurate and
has support in the literature. 6t can also be technique sensiti.e. 5he operator must be careful not
to o.er-manipulate the patient and place the cond)les in a more posterior position.
8hat does 'c7ee sa) about this techniqueC
'c7ee stated that the most important criteria for CR is the complete release of the inferior
lateral pter)0oid muscle durin0 =aw closure. 6f not released, the cond)lar position will be inferior.
Sin0le-handed technique" same as the bimanual but with one hand, fin0ers at the an0les and the
base of the thumb at the chin. 5he free hand is used to place the recordin0 medium. 'an) sa)
that it is not as accurate as bimanual manipulation.
+. ')otronics" not .er) popular toda). 3lectrodes measure muscle acti.it). Records are difficult
to .erif) and are anterior to CR compared to other techniques.
8hat does Jan1elson sa) about the neuromuscular aspects of occlusionC
Hnassisted free closure b) the patient ?swallowin0, pull ton0ue bac1@" no anterior depro0rammer.
Records tend to be anterior to repeatable CR compared to bimanual 0uidance.
$. Hnassisted free closure b) patient ?with anterior depro0rammer@" 8hat did Campos findC
,. ower Centric ?Roth@" this e>cellent technique is a modification of (uciaEs ori0inal wor1. A
flat plane anterior depro0rammer ?to pre.ent acti.atin0 the neuromuscular a.oidance
mechanism@ is combined with free closure b) the patient to eliminate operator induced error. 5he
use of the flat plane allows the ele.ator muscles ?masseter and temporalis@ to seat the cond)les in
a superior anterior position. 5he anterior depro0rammer is made without indentations to re0ister
the mandibular incisal ed0es. 5he ori0inal technique, used a two piece wa> bite. 'ore stable
re0istration materials li1e acr)lic resins can be used for the depro0rammer and an elastomeric
recordin0 material.
a. 5he patient is fitted with the anterior depro0rammer so the teeth are minimall) separated.
b. Durin0 the depro0rammin0 the patient is tau0ht to mo.e into CR without assistance.
c. 5he recordin0 material is introduced posteriorl) and the patient e>erts firm anterior bitin0
pressure on the
depro0rammer in the CR position while the material sets.
/ic1e) stated that artificial teeth will contact in CR when the proprioception of natural teeth is
absent. 5hree methods of recordin0 CR are discussed"
a. h)siolo0ic technique - swallowin0 procedures and chew in records. roblems - mo.ement
of rims on the
tissues, patient not reachin0 the most retruded position as he chews side to side, and
resistance of the
material ma) result in a lac1 of consistenc) in the mandibular position.
b. 9raphic indication of mandibular position I intraoral or e>traoral tracin0 de.ices. roblems -
supported b)
mo.able tissues, discrepanc) in opposin0 rid0e siAe or position.
Direct interocclusal records - made b) interposin0 recordin0 medium between occlusal rims.
Recommended b) /ic1e) because of its simplicit). roblem - Accurac) dependent on clinical
=ud0ement b) the dentist.
Recordin" $aterials:
CR recordin0 should alwa)s be .erified a0ainst a second recordin0.
Careful trimmin0 of the interocclusal recordin0 material is critical because the soft tissue is
recorded in a compressed state. 5he stone casts record the soft tissue in an uncompressed state.
5he two areas that must be trimmed are the 0in0i.al tissues of the ma>illar) teeth ?palatal@ and
the distal tissue of the terminal ma>illar) tooth.
8a>es" /ard baseplate or reinforced ?Aluwa>, Coprawa>@" 'an) .ariations in technique. 5he
material is 0enerall) considered too unstable and inaccurate for CR ?o1 if used immediatel),
must be no proprioception, must harden quic1l), 3>. Delar wa>.@, but can be used successfull)
for static ?positional@ lateral chec1bites.
Compound ?modelin0 plastic@" accurate but are technique sensiti.e. *eed to ha.e uniform
softenin0 to pre.ent une.en pressure while recordin0 CR.
laster and J43" accurate and stable but difficult and mess) to use.
3lastomeric ?Stat 2R, 2lu 'ousse, etc.@" stable, eas) to use and acceptable accurac). Se.eral
.ariations in technique. 8idel) accepted as the current norm.
%actors that affect Centric Relation records:
5he resilienc) of the supportin0 tissues.
5he stabilit) of the recordin0 bases.
5he 5'J and associated neuromuscular mechanisms.
5he character of the pressure applied in ma1in0 the recordin0.
5he technique used in ma1in0 the recordin0 and the associated recordin0 de.ices used.
5he s1ill of the dentist.
5he health and cooperation of the dentist.
5he ma>illomandibular relationship.
Character and siAe of the residual al.eolar arch.
5he siAe and position of the ton0ue.
8hat did 7in0er) sa) about problems associated with CRC
1. Requirements"
a. Record correct horiAontal relationship
b. 3qual .ertical contact of arches
!. 3rrors"
a. ositional - incorrect horiAontal and .ertical contact, e>cessi.e pressure on closin0.
b. 5echnical - poor rims, pin mo.ed, processin0 errors.
/ow are the errors manifested clinicall)C
;ertical - DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
/oriAontal - DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
Recordin0
a. 3>traoral and intraoral tracin0 - use a central bearin0 point to establish equal contact.
b. Direct chec1 bite - occludin0 surfaces must not touch. Recordin0 medium must be soft.
c. <unctional recordin0 K chew in - 0othic arch tracin0 made with pressure - be careful with
displaceable
tissue.
Shafa0h found what about CR and diurnal .arianceC.
8hat is his su00estion C
9uichet"
- /ow does the SC' muscle affect =aw positionC
- Can a dentist repro0ram the musculature and cond)lar positionC
- 8hat is the protecti.e refle>C
- /ow is equilibration related to =aw separationC
8illiamson - 8hat does he sa) bitin0 hard does to the cond)lesC
- 8hat does he sa) about forcefull) retrudin0 the mandible .s. a ph)siolo0ic position usin0 the
anterior 0uidance techniqueC
- 5he temporalis has more influence on CR than the masseter when an anterior 0uidance
appliance is used ?8illiamson@.
Campos - what did he sa) about recordin0 positions of CR in upri0ht or supine positionsC 8hich
one is betterC Did the) ha.e a difference in reproducabilit)C
Articulation:
1. 5he choice of the articulator is dependent on the intended occlusal scheme ?0roup function,
mutuall) protected@ to be de.eloped, the comple>it) of the restoration.
!. Semi-ad=ustable articulators are commonl) used, alon0 with arbitrar) facebows.
#. CR records should be less than # mm to minimiAe the arc of closure errors.
+. 5he de0ree of sophistication chosen will be ne0ated if accurate centric relation records are not
obtained and e>cessi.e intraoral ad=ustments -ma) be required.
&rosthesis fabricated in centric relation or centric occlusion:
(ucia recommended that centric occlusion should be built to occur at centric relation. Re0ardless
of
whether we belie.e that centric occlusion should be sli0htl) anterior to this terminal hin0e
position, this
is the onl) constant, repeatable position that can be used to chec1 the wor1 as we proceed.
8hat does he sa) about propriocepti.e impulsesC
9lic1man e.aluated a patient with full mouth restorations and placed one set fabricated in CR
and the
other in C4. 8hat did he findC
Serrano used a correcti.e occlusion prosthesis to tr) to impro.e the reproducabilit) of CR. 8hat
did
he find after the three month periodC
8ood used an interim prosthesis to allow for easier CR recordin0 later. 8hat did he recommendC
Conclusion:
1. 5he definition of CR has e.ol.ed o.er the )ears and with 0reater understandin0 of mandibular
mo.ement, it ma) chan0e a0ain. As the definition chan0ed, the techniques for recordin0 it often
chan0ed or were modified. 4ther modifications in technique are associated with the impro.ed
materials.
!. CR is an area, a small area.
#. 6n the 1%-0Es Bthe most retruded relationship of the mandible to the ma>illa when the cond)les
are in their most posterior unstrained positions in the 0lenoid fossa from which lateral
mo.ements can be made, at an) de0ree of =aw separationB. 5he chin point push bac1 technique
was popular.
6n the 1%&0Es BRH'B the rearmost uppermost and midmost position. Dawson and others pointed
out that clinicians tended to emphasiAe the rearmost aspect and, with manipulation b) the
operator, the patient recordin0 could actuall) end up posterior to CR. Chin point 0uidance was
followed b) the bimanual 0uided technique, both with and without anterior depro0rammin0.
5he clinician should select a technique and material for recordin0 centric relation position based
on the patientEs presentation, proposed treatment, and the clinicians personal philosoph).
References"
7apur An e.aluation of CR records obtained b) .arious techniques. JD ,",,0, 1%-,.
:ur1stas, <actors affectin0 CR records in edentulous mouths. JD 1+"10--, 1%$+.
'e)ers, CR records - historical re.iew JD +,"1+1, 1%&!.
8ipf, athwa)s to 4cclusion" 5'J Stereo0raphic Analo0 and mandibular mo.ement 6ndicator.
DC*A !#"!,1, 1%,%.
9uichet, 6nitial reference, procedures for occlusal treatment, Anaheim, 1%$%, Denar Corp.
'illstein, determination of the accurac) of wa> interocclusal re0istration. art 66 JD !%"+0,
10,#.
7inder1necht, 5he effect of a depro0rammer on the position of the terminal trans.erse horiAontal
a>is of the mandible. JD $#"1!#, 1%%!.
(ucia, 5echnique for recordin0 CR. JD 1+" +%!, 1%$+.
(on0, (ocatin0 CR with a (eaf 0au0e. JD !%"$0&, 1%,#.
Dawson, temporomandibular =oint pain-d)sfunction problems can be sol.ed . JD !%"100. 10,#.
8ood, Reproducibilit) of CR bite re0istration technique. An0le 4rthod 1%%+L $+?#@"!11.
Schalhorn, A stud) of the arbitrar) center of rotation and 1inematic center of rotation for
facebow mountin0. JD ,"1$!, 1%-,.

' Abstracts '
10'001( At)ood, D(A( A criti#ue of research of the osterior limit of the mandibular
osition( * &rosthet Dent +0:+1',-, 1.-/(
urpose" 5o discuss the concept of centric relation and e.aluate past, current, and need for future
research.
Discussion" 5here are two basic concepts of CR. 5he anatomic concept which states a most
posterior border position established b) li0aments. 5he pathoph)siolo0ic concept states that CR
is the most posterior unstrained =aw relationship not a border position and is established b)
muscle action. CR is important as a reference position for the restoration of occlusion due to it
bein0 relati.el) reproducible. 2ut reproducibilit) does not assure ph)siolo0ic desirabilit) or
correctness. A number of clinical and specific problem studies are re.iewed.
Conclusion" osterior limit of the mandible at ;D4 is established b) structures anterior and
lateral to the cond)les rather than posterior to them.?lateral pter)0oid and temporomandibular
li0ament@ 5he temporomandibular li0aments contain propriocepti.e ner.e endin0s susceptible to
stretchin0 leadin0 to inhibition of the retrusi.e muscles?temporalis and di0astrics@, and
stimulation of the protrusi.e anta0onist muscles ?lateral pter)0oids@.
5he need for a lar0e .ariet) of future studies is called for.
10'00+( $oss, $(0( A functional cranial analysis of centric relation( DC1A 1.:2,1'22+,
1.34(
urpose" 5his article is a re.iew of the information as to the anatom) of the 5'J and its
relationship to Centric position. 5he followin0 conclusions ha.e been made"
1. 6n biomechanical terms the centric relation is a nonfunctional position.
!. 4.er relati.el) lon0 periods of time, the morpholo0) of all functional surfaces of the 5'J is
capable of si0nificant adapti.e alterations. 5hese are normal compensator) responses of s1eletal
units to the prior alterations of functional matrices.
#. 6n much shorter time periods, the d)namicall) fluctuant state of the neuromuscular apparatus
ma1es it reasonabl) certain that intra-indi.idual .ariation in cond)lar positions can e>ist.
10'00,( 0e5y, &H( Clinical imlications of mandibular reositionin" and the concet of an
alterable centric relation( DC1A 1.:42,'430, 1.34(
Summar) of important points"
- 3arl) attempts to obtain repeatable positions in treatin0 denture patients resulted in a fi>ed
retruded position bein0 standard for centric relation. 5his concept was later used for dentate
patients. (e.) feels this is incorrect. 5he mandible repostures to a more fa.orable position to
establish a new balance and equilibrium. 5he cond)le and fossa remodel and adapt to this
position.
- 5he =oints assume their position as a result of the intercuspation of the teeth, =aws, and
neuromusculature.
- <orm follows function.
10'00,( 0e5y, &(H( Clinical imlications of mandibular reositionin" and the concet of an
alterable centric relation( DC1A 1.:42,'430, 1.34(
Discussion" A fi>ed retruded positional concept is traced to earl) complete denture attempts to
obtain duplicable bites. 5his concept, later 0ained acceptance as a ph)siolo0ic entit) for patients
with teeth. Static centric relation, ultimatel) lead to entirel) reproducible s)stems in.ol.in0 all
mandibular mo.ements. An interpretation of centric relation as fi>ed or static has become the
common cornerstone for .irtuall) subspecialties in dentistr). Accordin0 to (e.), a fi>ed retruded
positional concept has lead to unnecessar) treatment in certain orthodontic cases and
rehabilitation cases as related to e>tractions and sur0ical =aw repositionin0.
Reposturin0 the mandible to a clinicall) fa.orable B as if B position determined b) the
anatomic factors present is an inte0ral aspect of the reconstruction procedure. Control of the
situation requires that the newl) acquired intercuspation be definitel) 1e)ed to allow the patientsM
musculature to establish a new balance and equilibrium and time for the cond)les and their
fossae to readapt and remodel their relationship.
5emporomandibular articulation has a wide ran0e of adaptabilit) and remodelin0 capacit).
5he =oints assume their position as a result of interpla) of intercuspation of teeth , =aws and
neuromusculature. A d)namic concept of centric relation is presented as a quasi-fi>ed position of
temporar) duration which e>ists in a state of equilibrium established b) the neuromusculature
and li0aments. Adoption of this concept allows for a dia0nosis and treatment which is rational in
theor) and wor1able in fact.
10'002( *an6elson, 7( 1euromuscular asects of occlusion: 8ffect of occlusal osition on
the hysiolo"y and dysfunction of the mandibular musculature( DC1A +,:143'1-//, 1.34(
'echanical measurement performed under conditions for re0isterin0 cond)lar ?border@
occlusion does not establish whether the repetiti.eness is occurrin0 under muscularl) rela>ed or
muscularl) strained conditions. 5he presence of mechanical de.ises, such as clutches, central
bearin0s, or panto0raphs, which ha.e been used to measure border positions, elicit a
neuromuscular response b) their .er) presence.
5ranscutaneous electrical neural stimulation ?53*S@ is firml) established in ph)sical
medicine as a most effecti.e, ph)siolo0icall) rational means of rela>in0 specific areas of the
musculature. 5he ')o-monitor was desi0ned to adapt 53*S specificall) to the requirements for
the rela>ation and control of the comple> of muscles in.ol.ed in mandibular function. 5his is
accomplished b) the application of mild, time-spaced pro0rammed stimuli throu0h the fifth and
se.enth ner.es.
5racin0s in this stud) showed"
1. Chewin0 and swallowin0 were done at, or in the .icinit) of, centric occlusion and that no
chewin0 stro1es or swallows went to centric relation.
!. athwa)s between centric occlusion and centric relation is seldom a s)mmetric posterior
mo.ement, but in.ol.es chan0es in all dimensions.
#. 5he muscle tension 0enerated on retrusion from centric occlusion to centric relation 0i.es
further support to the findin0s that centric relation represents a neuromuscularl) strained
position. ?*ote" Definition of C.R. used" Rearmost, uppermost, midmost position@
+. Centric occlusion, apparentl) b) feedbac1 to proprioceptors, is the dictator and controller of
the posture and the s1eletal relationship of the mandible to the s1ull. 8hen centric occlusion
does not coincide with the neuromuscular position, propriocepti.e feedbac1 from the
malpositioned centric occlusion dictates and maintains strained muscle accommodation, and an
accommodati.e tra=ector) of closure. 5he result is mandible d)sfunction characteristic of
craniomandibular s)ndrome.
-. ')ocentric occlusion often coincides with centric occlusion, but in no instance was
m)ocentric occlusion found to coincide with centric relation.
$. Re0istration of m)ocentric occlusion is achie.ed b) isotonic muscle contraction that ori0inates
from rest position.
*ote" 5his author lists onl) # references, all of which are himself.
5his article is nothin0 more than an ad.ertisement for the ')o-monitor.
10'004( Da)son, &(8( 9timum :$* condylar osition in clinical ractice( ;nt * &erio Rest
Dent ,:11',1, 1./4(
urpose" 5o discuss, in len0th, the optimum cond)lar position in clinical practice.
Conclusion" Definition of C.R." 8hen the properl) ali0ned cond)le-dis1 assemblies are in the
most superior position a0ainst the eminentia, irrespecti.e of tooth position or .ertical dimension.
C.R. is a horiAontal relationship of mandible to ma>illa.
5he most important point in re0ard to cond)le-fossa relationship has been 0rossl) i0nored,
and that is the role that the medial pole pla)s as the predominant stop of upward mo.ement of
the cond)le.
8hen we ha.e occlusal interferences to the uppermost centric relation position, it means that
the lateral pter)0oids must de.iate the mandible to conform to the ma>imum occlusal position,
and the) cannot de.iate to that position without also ser.in0 as a holdin0 muscle a0ainst the
ele.ator muscles. 6f this pro0resses into a clenchin0 pattern, we are 0oin0 to then ha.e
h)perm)otonia and incoordinated musculature. 8hat we are reall) after is a totall) harmonious
relationship of functional harmon).
2ilateral manipulation is the method preferred to determine optimum 5'J cond)le position.
10'00-( <in"ery, R(H( A re5ie) of some roblems associated )ith centric relation( *
&rosthet Dent +:,03',1., 1.4+(
urpose" 5o discuss four problems associated with centric relation"
'ethodsGroblems discussed"
1. 8hat is required" roblem of requirements include the position of the horiAontal
relationship of the mandible to the ma>illa with equaliAation of .ertical contact, is 1nown
as centric relation, or the most retruded unstrained positions of the heads of the cond)les
in the 0lenoid fossa, at an) de0ree of =aw separation, from which lateral =aw mo.ements
can be made. 8e do not Bta1eB centric relation, we BrecordB centric relation.
!. 3rrors" 5here are two classes of error. Positional errors caused b) operator error in
recordin0 horiAontal or .ertical relationship, e>cessi.e closin0 pressures and chan0es in
supportin0 area. Technical errors ma) be caused b) ill fittin0 occlusion rims,
indiscriminate openin0 or closin0 of the occludin0 de.ice or articulator, sli0ht shiftin0 of
teeth in final wa> set-up to the permanent base material.
#. /ow errors manifest" (oss of retention particularl) in the mandibular denture, irritation
on the crest of the lower rid0e ?localiAed ulcer usuall) h)peremic@ in a premature contact,
premature contact of one or se.eral teeth on one side.
+. Recordin0 centric relation" 5his author feels that too man) operators are prone to accept
without question CR recordin0s without questions. <i.e methods are discussed.
1. 9raphic recordin0" Referred to as arrow point tracin0 and represents the mo.ement of the
mandible on one plane. 5he resultant 0raph will be ta1e the form of a ;. the point refers
onl) to the anteroposterior =aw relation and must be re0istered with equaliAed .ertical
pressure. 3rror can be made b) the amount of pressure applied b) the patient and
displacin0 the supportin0 tissue. Stansber) brou0ht out a method to chec1 the correctness
of the position of the central bearin0 point.
!. 3>traoral procedure" the 0othic arch tracin0 is de.eloped e>traorall), allowin0 full .iew
at all times. laster in=ected between the occlusion rims and central bearin0 point is used
as a recordin0 medium. Allows one to detect an) =aw mo.ement from the ape> of the
arch tracin0 and a.oids loc1in0 a patients =aw in a certain position.
#. 6ntraoral procedure" 9othic arch de.eloped while the central bearin0 point is loc1ed at
the ape> of the tracin0 and plaster is in=ected between the occlusion rims and central
bearin0 point as the recordin0 medium.
+. Direct chec1 bite method" 'ost common material is wa>. ?wa> distorts@ Secured on
occludin0 surfaces and made with equaliAed pressure.
-. <unctional recordin0 method" <requentl) call a chew-in, allows the patient to indicate the
position of CR b) functional mo.ement. Accomplished b) abrasi.e material, wa>, or
studs placed on the occlusal rims.
Summer)" 'an) methods are acceptable. 5he purpose of this paper is to stimulate more thou0ht
on the problems of recordin0 CR.
10'003( Wood, =(W( Centric relation and the treatment osition in rehabilitatin"
occlusions: A hysiolo"ic aroach( &art ;: De5eloin" otimum mandibular osture( *
&rosthet Dent 4.:-23'-41, 1.//(
urpose" 5he article discussed a ph)siolo0ical clinical approach to de.elopin0 optimum
mandibular posture and clinical methods of recordin0 this posture when rehabilitatin0 complete
occlusions.
'ethods N 'aterials" *one
Results" *one
Discussion" 5he purpose of occlusal orthopedic therap) is to 0i.e tissues a functional opportunit)
to approach their optimum ph)siolo0ic health. the prosthesis should pro.ide a firm nondeflecti.e
occlusion.
<abricatin0 occlusal orthopedic interim prosthesis" 'a1e acr)lic pro.isional restorations that
pro.ide optimum occlusion at the proper .ertical dimension. eriodic ad=ustments will be
necessar). 5his will allow for an easier recordin0 later.
5hree methods discussed to determine CR are free arcin0 b) the patient, resisted arcin0 with
patient bracin0, and manipulated arcin0 with dentist bracin0.
10'00/( Hic6ey, *(A( Centric relation, a must for comlete dentures( DC1A 1o5 1.-2:4/3'
-00(
Complete dentures ha.e no means of attachin0 to it bon) support so, to maintain stabilit), it is
necessar) for the opposin0 teeth to meet e.enl) on both sides of the arch within the normal
functional ran0e. CR is the onl) position within the functional ran0e that e.en contacts can be
established and therefor, it is a must for complete dentures. 5o eliminate error in a fabricated
denture, CR records must be made at the e>act ;D4 desired and accuratel) transferred to the
articulator. Reasons to construct a complete denture in CR are"
1. CR is the onl) position that can be routinel) repeated and reproduced in an edentulous patient.
!. 'ountin0 the casts in CR eliminates the problem of determinin0 how far anteriorl) to this
most retruded position centric occlusion should be established.
#. CR must be recorded to permit accurate ad=ustment of the cond)lar 0uidance of the articulator
for eccentric mo.ements.
+. 4pposin0 artificial teeth will li1el) contact in CR when the proprioception of the natural teeth
is absent.
-. An accurate CR record orients the lower cast in the correct relationship to the openin0 a>is of
the articulator.
5he author discusses three methods of recordin0 centric relation.
5he hysiolo"ic techni#ue includes swallowin0 procedures and chew-in records. 'o.ement of
the rims on the supportin0 tissue, the patient not reachin0 the most retruded mandibular position
as he chews side to side and resistance of the material used often result in a lac1 of consistenc)
in the mandibular position.
5he "rahic indication of mandibular osition is recorded usin0 intraoral and e>traoral tracin0
de.ices. 5he recordin0 elements bein0 supported b) mo.able tissues and an) discrepanc) in
opposin0 rid0e siAe or position can result in erroneous records.
Direct interocclusal records are made b) an interposin0 recordin0 medium between occlusal
rims. 5he author prefers this method because of itMs simplicit) and lac1 of mechanical de.ices.
/e warns that accurac) is dependent on clinical =ud0ement b) the dentist and cooperation
between the dentist and patient.
10'00.( =lic6man, et( Al( :elemetric comarison of centric relation and centric occlusion
reconstruction( * &rosthet Dent ,1:4+3'4/+, 1.34(
urpose" 5o stud) a completel) reconstructed natural dentition under actual function to
determine whether CR or C4 relationships are used durin0 chewin0 and swallowin0.
Discussion" 5wo full mouth restorations were made for a patient, one fabricated with casts set in
intercuspation and the other with casts in CR. 5elemetr) tests were conducted to determine how
each set-up affected the tooth contact patterns durin0 function. *o si0nificant chan0e in the
frequenc) of contacts and 0lides occurred after placin0 either reconstruction e>cept after three
wee1s of wearin0 the set-up built in CR. 5he findin0s indicated that ad=ustin0 to an occlusion set
in CR does not readil) happen in the three wee1 testin0 period. 5he patient tended to function in
the e>istin0 C4 position. 5he author concludes that the use of the terminal hin0e a>is in oral
rehabilitation is sub=ect to question because the patient will not function in this position.
5he distance between CR and C4 is .ariable and unpredictable so the use of the terminal
hin0e as a reference point is also questionable. CR is tolerated in complete denture set-ups
because the proprioception of the D( does not e>ist an)more.
10'010( Shafa"h ;, >oder *0, :hayer <8( Diurnal 5ariance of centric relation osition( *
&rosthet Dent ,2:432'4/+, 1.34(
urpose" 5o in.esti0ate diurnal chan0es in centric position within a period of one da).
'aterialsG'ethods" 5en men and three women with An0le Class 1 occlusions, ran0in0 in a0e
from !0 to #0 )ears of a0e, with no e.idence of s)stemic or ph)siolo0ic d)sfunction and normal
5'Js. Centric relation was repeatedl) recorded for thirteen patients at %"00 a.m., #"00 p.m., and
%"00 p.m. on a sin0le da). Denar model D+A articulator was used with a 1inematic facebow at
each appointment for consistenc). 5he dentist used the chin point 0uidance technique for
positionin0 the mandible usin0 an anterior pro0rammer, also called B anterior stopB or Banterior
=i0B. 5o a.oid sub=ect fati0ue the entire procedure was done in appro>imatel) !--minute
appointments separated b) --O hours rest.
ResultsGDiscussion" ;arious positions of the cond)les obser.ed on sa0ittal tables could be
attributed to 1@ nonad=ustabilit) of the intersa0ittal distance of the instrument to the intercond)lar
distance of each sub=ectL !@ the inabilit) of the patients musculature to allow a pure hin0e
mo.ementL #@ diurnal .ariance in the 5'JL +@ .ariations in location the hin0e-a>is and
transferrin0 it to the articulatorL -@ in.alidit) of the stationar) hin0e-a>is theor).
Conclusions" 4n the basis of the anal)sis of the data collected in this e>periment, the followin0
conclusions were made"
1. Centric relation was repeatable for a few patients but in most there was .ariation. 5he
0reatest .ariation
was in the superoinferior direction. 5here was no time of minimum .ariabilit).
!. 6n man) patients the cond)les were in their most anteroinferior position in the mornin0 and
in their most
superoposterior position in the e.enin0. 5his ma) indicate that there is a diurnal pattern in
the position of
centric relation possibl) related to fluid content in the =oint.
#. Dependin0 on oneMs definition of centric relation, one time of da) ma) be fa.ored o.er
another due to diurnal
bias. 6f the most retruded and superior position of the cond)les is desired, the e.enin0
seems to be a better
time for ma1in0 CR records.
+. <reedom to mo.e to some de0ree around a clinicall) determined centric relation position
ma) ha.e merit
as a treatment philosoph).
10'011( =ilboe, DR( Centric relation as the treatment osition( * &rosthet Dent 40:-/4'-/.,
1./,(
urpose" 5o anal)Ae the morpholo0) of the 5'J not as a bone to bone mechanism, but as a bone
to tissue to bone mechanism.
'aterials N 'ethods" *one
Results" *one
Discussion" 5he position of the disc id important in centric relation as the middle Aone or central
bearin0 area has no .ascularit) or inner.ation and therefore is adapted to accept pressure.
Centric relation redefined" 5he most superior position of the mandibular cond)les with the
central bearin0 area of the disc in contact with the articular surface of the cond)le and the
articular eminence. 5his position ma) not alwa)s be possible to obtain due to anterior dislocation
of the disc.
10'01+( Williamson 8(H(, et al( Centric relation: A comarison of muscle determined
osition and oerator "uidance( Am * 9rtho 33:1,,'124(
urpose"
1. 5o determine the direction and ma0nitude of shifts in cond)lar position when an interocclusal
record is formed b) bitin0 hard or eas) on a leaf 0au0e usin0 J43 as compared to the use of a
wa> interocclusal record.
!. 5o determine whether the temporal or the masseter muscles are most acti.e in seatin0 the
cond)les in centric relation when a leaf 0au0e is used.
'ethods N 'aterials" 5he sample consisted of fifteen adults, !1-#- )ears of a0e. 5he ;erichec1
instrument was used to compare the cond)lar position when different interocclusal records were
made usin0 three separate techniques of recordin0 centric relation.
1. /ard bite on the leaf 0au0e for - min.
!. 2ite Bhalf as hardB as technique P1
#. 2ite into pin1 wa> while 0uided b) the operator.
3lectrom)o0raphic recordin0s were concomitantl) made.
Conclusion"
1. 2itin0 hard tends to cause the cond)les to be forced posteriorl) and awa) from the articulatin0
surface of the eminence.
!. 2itin0 eas) with the leaf 0au0e allow the ph)siolo0ic placement of the cond)les in the 0lenoid
fossa.
#. 5he temporalis muscles ha.e more influence upon centric relation cond)lar position than the
masseter muscles.
10'01,( Serrano, &(:( and 1icholls, *(;( Centric Relation Chan"e Durin" :heray )ith
9cclusal &rostheses( * &rosthet Dent 41:.3'104, 1./2(
urpose"
1. 5o e.aluate the chan0e in location of centric relation with time
!. 5o disco.er if CR stabiliAes within a period of # months in patients under0oin0 correcti.e
occlusion prosthesis therap)
'aterials N 'ethods" 3le.en patients, !--+& )ears of a0e, were selected.
P1 A modified (ucia =i0 was made for each patient. 5he patientMs =aw was 0entl) 0uided to close
until contact was made with the anterior =i0GJ43 recordin0 medium. Casts were fabricated and
mounted usin0 the J43 record.
P! A correcti.e occlusion prosthesis were fabricated and inserted. Records were made after
1,#,,,1+,#0,and %0 da)s.
Reference points were established on the mounted casts and measurements made.
Results"
1. Correcti.e occlusion prosthesis therap) did not impro.e the reproducibilit) of centric relation
in as)mptomatic patients.
!. Centric relation is not one position but is a ran0e of positions.
#. 5he ran0e of CR .ariation is 0reater laterall) than antero-posteriorl).
10'012( 0ucia, ?(0( Centric relation ' theory and ractice( * &rosthet Dent 10:/2.'/4-, 1.-0(
urpose" 5o locate a BcenterB that will enable us to reproduce the patientMs mo.ements on a
suitable articulator and e>ecute our wor1 more intelli0entl) and with 0rater ease.
rinciples N 2eliefEs"
1. 5here is one hin0e a>is.
!. 2) the use of twin 9othic arch tracin0s in the horiAontal plane, it is possible to locate the
centers of lateral mo.ement and can be duplicated on an articulator that has an ad=ustable
intercond)lar distance.
#. Centers of rotation are made of two components, the center of .ertical motion and the center
of lateral motion, one in the same center, one in each cond)le.
+. ropriocepti.e impulses are responsible for the awareness of the position of the mandible in
space, natural refle> acts of the mandible are to close in a lateral or lateral protruded position.
5herefore the patient must be decei.ed b) 1eepin0 the teeth apart. 5he patient must be trained
and 0uided to e>ecute the terminal hin0e action.
-. (ucia method to record an interocclusal record to mount the lower cast to the articulator usin0
5ena> wa>, Sure-Set wa> and Aluwa>.
$. 6t is necessar) to transfer the centers of lateral motion to an articulator if the other mo.ements
ha.e been reproduced, this is accomplished b) the use of twin 9othic arch tracin0s on a suitable
articulator which can be ad=usted for intercond)lar width.
Summar) N Conclusion"
1. 2) ha.in0 the centric relation of the mandible to the ma>illae properl) related on an
articulator, the dentist can de.elop the centric occlusion accuratel) accordin0 to his own
specifications.
!. <unctional mo.ements must seat the cond)le in the terminal hin0e position, Centric occlusion
should be built to occur at centric relation.
#. Re0ardless of whether we belie.e that centric occlusion should be sli0htl) anterior to this
terminal hin0e position, this is the onl) constant, repeatable position that can be used to chec1
the wor1 as we proceed.
10'014a( =uichet, 1 %( 7iolo"ical la)s "o5ernin" functions of muscles that mo5e the
mandible( * &rosthet Dent ,3:-2/'-4-, 1.33(
urpose" 5o clarif) if occlusal contacts cause specific responses in particular muscle 0roups and
if there are precise laws which quantif) the responses of the muscles to a particular occlusal
contact pattern.
'aterials N 'ethods" Description of how to formulate a stud) based on clinical obser.ations.
*o sub=ects described other than three 0eneraliAed 0roups of stud) h)pothesis to support clinical
obser.ations.
Clinical 4bser.ations" 5he reciprocal muscle response induced in the SC' muscle b) functions
of the lateral pter)0oid muscle to ad.ance the cond)le can be demonstrated b) 0raspin0 the bell)
of the ri0ht SC' and pull in a lateral directionL b) pressin0 at the opposite side of the mandible
at the premolar site a response is felt at the SC'.
(ateral pter)0oids will be in chronic contraction for the patient who has an occlusal condition
that pro0rams both cond)les to be maintained in an ad.anced position so that the teeth can fit in
'6. Chronic muscle contraction will be felt in both SC' muscles which results in chronic pain
in the bac1 of the head and nec1.
Just as the occlusion pro0rams functions to locate the mandible in the horiAontal plane, the
occlusion will also pro0ram muscle functions to locate the mandible in the .ertical plane.
A deflecti.e contact in CR on the mesial incline of the lin0ual cusp of the ma>illar) ri0ht
second molar causes pain in the ri0ht lateral pter)0oid muscle ?commonl) dia0nosed as earache@
and in the ri0ht SC' ?nec1 pain@ or ri0ht occipital re0ion at the attachment of the SC' ?pain on
bac1 of the head@. 4cclusal contacts can pro0ram responses in the muscles that mo.e the
mandible and reciprocal responses in their anta0onists to produce s)mptoms frequentl)
dia0nosed as B referred painB.
Summar)" 'an) factors other than proprioception ori0inatin0 from occlusal contacts of teeth
pro0ram =aw position and the functions of the muscles that mo.e the mandible. 4nce this is
understood, an accurate dia0nosis can select the course of patient treatment.
10'014b( 1iles %( =uichet, D(D(S( 7iolo"ic la)s "o5ernin" functions of muscles that mo5e
the mandible( &art ;;( Condylar osition( * &rosthet Dent ,/:,4'21, 1.33(
urpose" specific muscle responses pro0rammed b) specific t)pes of occlusal contacts, based on
clinical obser.ation of modified muscle responses related directl) to occlusal treatment
procedures.
5he direction of the resultant force .ector to the occlusal loadin0 determined propriocepti.el),
0o.erns functions of the muscles that mo.e the mandible.
6f occludin0 forces are applied parallel to the lon0 a>is of the tooth, the tooth has ma>imum
load bearin0 abilit) without propriocepti.e sensors si0nalin0 for inhibition of the application of
the load. 6f the applied forces are not in the direction of the lon0 a>is of the tooth upon
application of a relati.el) minor load, certain periodontal li0aments will be stresses to their
ph)siolo0ic limits, initiatin0 a propriocepti.e si0nal to inhibit further application of the load.
5here is a ph)siolo0ical limit to the amount of stress which the periodontal fiber can
withstand.
6n order to pre.ent dama0e durin0 chewin0, periodontal li0aments are equipped with the
propriocepti.e mechanism 5his si0nal induces a protecti.e muscle response such as an openin0
refle> or inhibited mo.ement.
Cond)lar position" Cond)lar positions of the mandible at rest as it mo.es to ma>imum
intercuspation are pro0rammed b) the occlusal scheme.
5he abilit) of the dentist to modif) the occlusion and repro0ram the cond)lar position and
muscle response is easil) demonstrated clinicall) in occlusal treatment procedures.
8hen clutches are remo.ed, the teeth do not fit to0ether properl). After se.eral =aw closures
the muscles repro0rammed the cond)lar position to complement the pre.ailin0 occlusion. 5his
phenomenon illustrates the potential of the dentist to almost instantl) repro0ram the musculature
and cond)lar position b) occlusal treatment.
5he abilit) of the occlusion to pro0ram cond)lar position accounts for the patientEs repeated
abilit) to a.oid dama0e.
atients a.oid occlusal contact on prematurities.
5he challen0e in obtainin0 an accurate centric relation record is not so much one of obtainin0
an inde>in0 re0istration of the mandibular teeth to the ma>illar) teeth as it is one of how to
relie.e stress in the muscles or repro0ram them so the) will allow the cond)les to see1 and retain
the position of centric relation.
10'014c( 1iles %( =uichet, D(D(S( 7iolo"ic la)s "o5ernin" functions of muscles that mo5e
the mandible( &art ;;;: Seed of closure ' maniulation of the mandible( * &rosthet Dent
,/:132'13., 1.33(
urpose" 5o stud) the effects of occlusal contacts on the muscles that mo.e the mandible
Discussion" 5his is the third part of a series that deals with how specific muscle responses are
pro0rammed b) specific t)pes of occlusal contacts. 5he article re.iews a model to facilitate in
de.elopin0 =aw-manipulation s1ills.
5here are four Bindependent personalitiesB in this scenario, the dentist, the atient, the
atients rotecti5e refle@es, and the "nathostomatic system(
2asicall), when the dentist approaches the patient to ma1e a CR re0istration the patient
BbracesB ?protecti.e refle>es@ for a potential dama0in0 premature occlusal contact.
/ence, there is a there is a pro0rammed muscular response to brace the cond)les in the most
ph)siolo0ic or protected mandibular position in consideration of the e>istin0 occlusal condition.
5he author compares the deflecti.e occlusal contact to an irritation. As an analo0), if a patient
had an e>tremel) sore wrist, the doctor must approach the area slowl) and carefull) so as not to
induce a protecti.e refle> in a patient. 5his is in contrast to a patient with a .a0uel) sore, chronic
wrist pain. /ere the doctor could approach the sore part with 0reater speed before a protecti.e
refle> would be initiated.
5he same situation is true with teeth, with respect to the speed the dentist can forcibl) arc the
mandible in CR, as deflecti.e occlusal contacts are remo.ed in occlusal equilibration.
5hree e>amples are 0i.en for centric prematurities on the lin0ual cusp of a first molar, cuspal
inclines of a second molar, and on steep inclines on the posterior se0ments of dental arches, the
last e>ample with occlusal contact on steep inclines is the most difficult to manipulate the
mandible into centric relation. 5his is because since the .ector of force is contrar) to the lon0
a>is of the tooth, the abilit) of the tooth to tolerate an occlusal contact in CR is limited.
10'014d( 1iles %( =uichet, D(D(S( 7iolo"ic la)s "o5ernin" functions of muscles that mo5e
the mandible( &art ;?: De"ree of Aa) searation and otential for ma@imum Aa)
searation( * &rosthet Dent ,/:,01',10, 1.33(
urpose" 5o emphasiAe that there definite principles b) which muscles respond to occlusal
contacts.
Discussion" 5his the fourth and last part to a series on the biolo0ical laws 0o.ernin0 functions of
muscles that mo.e the mandible.
5he article discusses how a patient will also e>hibit a Bprotecti.e refle>B to the hin0e openin0
of the mandible dependin0 on the occlusal prematurit) in centric relation.
5he distance that the patients mandible can be depressed from occlusal contact before the
patients musculature inhibits further openin0 ?protecti.e refle>@ is termed the ph)siolo0ic Aone of
=aw manipulation. 5his is a protecti.e refle> in the patients musculature, desi0ned to pre.ent
dama0e to the tooth that first ma1es occlusal contact in closure at that cond)lar position.
5he more equilibrated the patient is , the hi0her the ph)siolo0ic Aone, ie there is a
neuromuscular release and the mandible mo.es without interference from the muscle.
An e>ample here is a premolar with a deflecti.e occlusal contact will allow onl) !00 stress
bearin0 units which is the ph)siolo0ic limit load of that tooth. 5his would be equal to !mm.
6n a dentition that had a full complement of teeth, with four posterior teeth that had
simultaneous contact, there would be 1#00 stress bearin0 units which would equal to 1#mm of
the hysiolo"ic Bone of Aa) maniulation.
5he ph)siolo0ic Aone is also decreased b) the loss of periodontal li0ament and the driftin0 of
teeth.
A sin0le anterior restoration ma) cause a deflecti.e occlusal contact when the mandible is in
CR thus pro0rammin0 the retractor muscles ?posterior bell) of the temporal and di0astric@ to
function and protect the tooth from trauma. 6n some clinical situations, a wa> pro0rammer ma)
be used to promote simultaneous e.en contact of the anterior teeth ?this rela>es the ele.ator and
depressor muscles of the mandible@ and facilitate a more accurate centric relation record.
6n clinical situations, an anterior Ai" ma) be used to disen0a0e premature posterior tooth
contacts, which cause splintin0 of the cond)les b) lateral pter)0oid muscles.
Conclusion" *euromuscular release of the mandible ma) be accomplished b) equilibration of the
natural occlusion, orthodontics, restorati.e procedures, or sur0er). 'ost of the time it is a
combination of these procedures. 5he criteria for success is not the method utiliAed, but the
neuromuscular response to the treatment.