Centric relation

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CENTRIC RELATION

INTRODUCTION

To maintain stability of complete dentures, the opposing teeth

must meet evenly on both sides of the dental arch when the teeth

contact anywhere within the normal functional range of mandibular

movement. An occlusion for complete dentures that provides these

even contacts can be developed only when centric occlusion is in

harmony with centric relation.

Centric relation is a reference relationship that is constant for

each patient. Therefore it is the reference against which the desired

occlusal condition should be coordinated.

DEFINITION

The maxillomandibular relationship in which the condyles

articulate with the thinnest avascular portion of their respective

discs with the complex in the anterior-superior portion against the

shapes of the articular eminences. 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).

Centric relation is the most posterior position of the mandible

relative to the maxillae at the established vertical dimension.

(Boucher)

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HARMONY BETWEEN CENTRIC RELATION AND CENTRIC

OCCLUSION

Centric is an adjective and must be used with either relation

or occlusion to be specific and meaningful. Centric relation is a

bone-to-bone relationship whereas centric occlusion is a

relationship of upper and lower teeth to each other. Once CR is

established, CO can be built to coincide with it or to provide a

broad area of tooth contact in this position (A so-called freedom in

centric).

In edentulous subjects the lack of teeth, and consequently of

any centric occlusion, makes it necessary to use CR as a reference

position. Due to loss of teeth and impulses patient cannot avoid

deflective contacts and this defective occlusal contacts in CR cause

movement of denture bases and displacement of the supporting

tissues or direct the mandible away from this relation. So in order to

avoid this we make CO and CR to coincide.

ORIENTING CENTRIC RELATION TO THE HINGE AXIS

When the upper cast is correctly oriented to the hinge axis of

the articulator by an accurate face-bow transfer, the lower cast will

also be correctly oriented to the opening axis of the instrument

when it is mounted with an accurate CR record. This is true because

the mandible was in its most retruded position relative to the

maxillae both for locating the transverse hinge axis and for

recording CR. When the CR record is made at or very close to the

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desired vertical dimension of occlusion, little or no change (opening

or closing) will be necessary on the articulator and the likelihood of

errors from this source will be greatly reduced.

SIGNIFICANCE OF CENTRIC RELATION

1. To get stability of dentures

2. It is the horizontal reference position and helps the dentist

in verification purposes

3. For proper orientation of the lower cast

RECORDING CENTRIC RELATION

1. Conflicting concepts and objectives

There are basically two different concepts in the making of

CR records:

a. The record should be made with minimal closing pressures

so the tissues supporting the bases will not be displaced while the

record is being made.

b. The records should be made under heavy closing pressure

so the tissues under the recording bases will be displaced while the

record is being made.

2. Complications in recording centric relation

a. The structure of the TMJs is such that one joint can be

displaced downward by uneven pressure when records are made and

yet the condyles will still be in their most retruded position. This

situation cannot occur on the articulator, and thus a deflective

occlusal contact is produced which may be the source of instability,

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soreness, and resorption despite the correctness of the other

relations.

b. The resiliency that is present in both the mucosa and the

TMJs will not allow Thus, undue pressure in securing the relation.

c. It often is lost in the cast-mounting procedure and

processing of dentures.

3. Retruding the mandible to centric relation

One of the most difficult and most important tasks is

retruding the mandible to its centric relation. Some of the

difficulties encountered are biologic, psychologic, and mechanical.

a. The biologic difficulties arise from a lack of coordination

in groups of opposing muscles when the patient is requested to close

in the retruded position.

b. The psychologic difficulties involve both the dentist and

the patient. The more the dentist tries to overcome the apparent

inability of the patient to retrude the mandible, the more confused

the patient may become and the less likely he is to respond to the

directions provided by the dentist.

c. The mechanical difficulties encountered in securing CR

records are due to poorly fitting base plates.

4. Methods for assisting the patient to retrude the mandible

A number of methods are used to assist the patient in retruding

his mandible.
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Instruct the patient by saying, Let your jaw relax, pull it back,

and close slowly and easily on your back teeth.

Instruct the patient by saying, Get the feeling of pushing your

upper jaw out and closing your back teeth together.

Instruct the patient to protrude and retrude the mandible

repeatedly while he holds his fingers lightly against his chin.

Instruct the patient to turn the tongue backward toward the

posterior border of the upper denture.

Instruct the patient to tap the occlusion rims or back teeth

together repeatedly.

Tilt the patients head back while the various exercise just listed

are carried out.

Palpate the temporal and masseter muscles to relax them.

The simplest, easiest, and often most effective way of causing

a retrusion of the mandible to CR is by verbal instruction to the

patient. Let your lower jaw relax, pull it back, close on your back

teeth. These instructions must be given in a calm and confident

manner.

5. Requirements for Recording Centric Relation

The three primary requirements for making a centric relation

record are:

To record the correct horizontal relation of the mandible to the

maxillae

To exert equalized vertical pressure

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To retain the record in an undistorted condition until a previous

record can be verified

6. Methods of recording centric relation

Classified as static or functional

I. Static Method

Intraoral records in the static class are made with wax or

plaster, with or without a central bearing point and with or without

intraoral or extra oral tracing devices to indicate the relative

position of the two jaws.

(i) Technique for graphic method.

a. Extra oral tracing device [fig:5-6]

The technique for an extra oral arrow point tracing using a

Height tracing device is as follows (1931):

Make accurate, stable maxillary and mandibular record bases

Attach occlusion rims of hard base plate wax

Contour the wax occlusion rims

Establish the vertical dimension of jaw separation with the

mandible at physiologic rest

Reduce the mandibular occlusion rim to provide excessive

interocclusal distance

Make a face-bow transfer and mount the maxillary cast

With soft wax make a tentative centric relation record at the

predetermined vertical dimension of occlusion

Adjust the articulator with the condylar elements secured against

the centric stops

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Relate the maxillary occlusion rims in the soft wax record and

attach the mandibular cast to the articulator with plaster

Mount a central bearing device. Exercise care to center the

central bearing point in relation to the plate, both antero-

posteriorly and laterally.

Mount the tracing device. Be sure to attach the devices securely

to the occlusion rims. The stylus is attached to the maxillary rim

and the recording plate to the mandibular rim. This arrangement

develops an arrow point tracing with the apex anteriorly. The

reverse develops an arrow point tracing with the apex posterior.

Seat the patient, with head up right, in a comfortable position in

the dental chair.

Seat the record bases with the attached recording devices.

Inspect the record bases and recording devices for stability.

Make sure that there is no interference between the occlusion

rims when the mandible is moved in any direction. Lower the

stylus to the recording plate and determine that the stylus

maintains contact with the recording plate during mandibular

movements.

Retract the stylus and conduct training exercises with the patient.

Place the tips of the index fingers under the mandible near the

chin. Calmly and quietly instruct the patient to move the jaw

forward, backward, and to the right and left while gently apply

guiding pressure with the thumb. It is possible to dislodge the

mandibular record base by improperly placing the thumbs or by

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exerting excessive pressure. The Ney Excursion Guide is an aid

in training the patient. [fig:3]

When the patient is proficient in executing the mandibular

movements, prepare the tracing plate to record the tracing. A thin

coating of precipitated chalk in denatured alcohol applied evenly

with a brush provides a medium that offers no resistance to the

movement of the stylus and produces a clearly visible tracing.

Develop an acceptable tracing by dropping the stylus to the

record plate.

When a definite arrow point tracing with a sharp apex [fig:7] is

made have the patient retrude the mandible to centric relation.

The point of the stylus should be at the point of the apex of the

arrow point of tracing. Inject quick setting dental plaster between

the occlusion rims and allow the plaster to harden.

Remove the assembly and mount the mandibular cast with the

new record.

This record is a tentative record and will be checked with an

interocclusal check record when the teeth are arranged and the wax

is contoured.

b. Intra oral tracing device [fig:4]

The intraoral, arrow-point tracer combines a central bearing

and a tracing device. Generally, it has a pointed screw-in bearing

and tracing device mounted on the maxillary rim and a plate

mounted on the mandibular rim. The plate is covered with a marking

substance such as thin lacquer or a thin layer of dark-colored wax.

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The central bearing pin is corrected to the proper vertical dimension

(usually on the articulator), and when the occlusion rims are in

place, the patient is instructed to perform lateral and protrusive

movements. As these movements are performed, the Gothic arch

form is traced on the plate.

If the tracer is on the maxillary occlusion rim, the apex

anteriorly represents the most retruded position from which lateral

excursions are made, because all protrusive movements occurs

posterior to the apex. The stylus is mounted on the lower trial base;

the apex (centric relation) will point posteriorly. This concept was

first propounded by Hesse in 1897 and was popularized by Gysi

(1908, 1929). A hole may be drilled in the plate at the apex of the

intraoral tracing, or a plastic disk with a hole in it may be placed

over the apex of the tracing. The hole or depression is used to

ensure that the patients jaw is in the retruded position while the

registration is being recorded with plaster or some such material.

Advantage

The advantage of the intraoral tracer is that the bearing-

tracing point must be stout enough to resist biting pressures and

therefore can be held in any chosen position by means of a locking

disk or washer. This disk is luted on the plate with sticky wax in

the appropriate position (centric, lateral, or protrusive).

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Disadvantage

The disadvantage of the intraoral tracer lies in the relative

difficulty of visualizing the tracing.

c. Modifications in tracers

Philips 1930

Sears 1949

Terrill 1951

Robinson 1952

Koper 1959

The static method has the advantage of causing minimal

displacement of the recording bases in relation to the supporting

bone.

(ii) Verification Methods

Technique for tactile or interocclusal check record method.

The technique for a tactile check record is divided into two

steps:

a. Tentative records using occlusion rims attached to accurate

stable record bases

b. Interocclusal check records with the teeth arranged for try-

in.
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The technique includes these steps:

Seat the patient comfortably with the head upright.

Contour the maxillary occlusion rim, lip lines, distal cuspid

points, and occlusal plane. Place the notch to aid in seating

records.

Establish the vertical dimension of jaw separation with the

mandible at rest and measure the distance.

Reduce the mandibular occlusion rim to allow excess

interocclusal distance.

Make a face-bow transfer record.

Using base plate wax, make a tentative centric relation record

by having the patient retrude and close the jaws until he feels

the closure to be at the tentative vertical dimension of jaw

separation.

Compare the measurements of the face at vertical dimension

of occlusion with the vertical dimension of rest position. The

measurement must be less for the vertical dimension of

occlusion.

Adjust the condylar elements of the articulator and secure

them against the centric stops.

Mount the maxillary cast, using the face-bow transfer record.

Secure the centric relation record to the maxillary occlusion

rim and position the mandibular cast.

Attach the mandibular cast to the articulator with plaster.

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Steps to be followed at the time of try-in of teeth are as

follows:

Seat the patient comfortably with the head upright and

supported by the headrest under the occiput.

Seat the maxillary record base. If the retention is not

adequate, apply a fine dusting of denture adhesive to the wet

tissue surface of the maxillary record base.

Seat the mandibular record base. Do not let the patient make

tooth contact. If a premature tooth contact exists with the

jaws in centric relation, the patients proprioception may not

direct the return to this identical position. Place two cotton

rolls bilaterally between the maxillary and mandibular

posterior teeth and have the patient to close the teeth on the

cotton and hold them together for several seconds. Do not

fatigue the patient in this position. This procedure allows the

maxillary record base to seat properly to the supporting

tissues.

Remove the mandibular record base and rehearse the patient

in protruding and retruding the lower jaw.

Dry the mandibular posterior teeth.

Adapt two thickness of softened aluwax to the occlusal

surfaces of the bicuspids and molars and extend over the

buccal and lingual surfaces. Exercise care not to trap air

under the wax. Resoften the wax with a controlled flame from

an alcohol torch or in a water bath at 130 o F.

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Seat the mandibular record base. Place the tips of the index

fingers on the buccal flanges of the record base in the area of

the second bicuspids and rest the tips of the thumbs under the

border of the mandible at the chin point The fingers help

stabilize the record base, and the thumbs are used as guides.

Calmly ask the patient to move the lower jaw back and close

on the back teeth. Ask him to stop closing when contact is

made.

Allow the wax to harden. Remove and dry the occlusal surface

of wax with a gentle stream of cool air.

Inspect the record to see that no cusp tip penetrated to make

tooth-to-tooth contact. If the original record was accurate in

the vertical direction, the cusp tips should penetrate the wax

equally on both sides.

Remove the maxillary record base, dry the occlusal surfaces

of the posterior teeth with air, and place it on the maxillary

cast.

Release the horizontal condylar guide locks on the articulator.

Place the mandibular record base and attached record on the

mandibular cast. The buccal third of the record is carefully

removed to expose the cusp tips.

Carefully seat the maxillary teeth in the record.

Observe the condylar elements. If the record is the same as

the original record, the condylar elements will rest against the
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centric stops in the same position as when the casts were

originally mounted.

If one or both condylar elements are not against the stops,

then one or the other record is inaccurate.

Failure to make check records that repeat will necessitate a

new mounting and further verification of the accuracy of the new

mounting record with check records until the three records agree.

Occlusal indicator wax is another method of checking the

articulator mountings for accuracy. This method is particularly

advantageous when arranging non-cusp form posterior teeth. The

technique for the use of occlusal indicator is as follows:

Place the trial dentures on the mounted cast.

Dry the occlusal surfaces of the posterior teeth with a stream

of warm air.

Raise the incisal guide pin from the incisal guide table and

secure it.

Place red articulating paper over the occlusal surfaces of all

mandibular posterior teeth.

Secure the condylar elements in the centric relation position.

Tap the teeth together to record the tooth contacts.

Place one thickness of occlusal indicator wax over the incisal

edges and occlusal surfaces of the mandibular teeth.

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Insert the trial dentures and instruct the patient to tap on the

posterior teeth. In difficult situations it may be necessary to

guide the patient.

Remove the mandibular trial denture and inspect the indicator

wax. If the mounting is accurate, the wax will penetrate to

expose the red markings.

II. The Functional Methods

The records in the functional class include the various chew-

in techniques suggested by Needles, House, and Essig and Paterson.

They also include methods that make use of swallowing for

positioning and recording the relative position of the jaws. The

patient produces a pattern of mandibular movements by moving the

mandible to protrusion, retrusion, and right and left lateral.

The Needles-House (1918) [fig:1] method used compound

occlusion rims with four metal stylii placed in the maxillary rim.

When the mandible moves with the styli contacting the mandibular

rim, the styli cut four diamond shaped tracings. The tracings

incorporate the movements in three planes, and the records are

placed on a suitable articulator to receive and duplicate the record.

The record can also be used as a centric relation record on other

types of articulators.

The Patterson (1923) method [fig:2] uses wax occlusion rims.

A trench is made in the mandibular rim and a mixture of half plaster

and half carborundum paste is placed in the trench. The mandibular

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movements generate compensating curves in the plaster and

carborundum. When the plaster and carborundum are reduced to the

predetermined vertical dimension of occlusion, the patient is

instructed to retrude the mandible and the occlusion rims are joined

together with metal staples.

Both of these methods are based on the same principle and

require a tentative interocclusal wax record of centric relation at the

tentative vertical dimension of occlusion to prepare the recording

devices. Both methods adjust the recording mediums at a height of

vertical jaw separation, which is in excess to the predetermined

dimension of occlusion. The correct vertical dimension of occlusion

is established as the patient closes the mandible.

The functional methods of recording centric relation require

very stable record bases and good neuromuscular coordination.

Disadvantage

Causing of lateral and anteroposterior displacement of the

recording bases in relation to the supporting bone while the record

is being made

III. Another method

According to Winkler, to record centric relation first we have

to establish the vertical dimension. Remove about 3-mm of the

mandibular rim from the first premolar area distally to the end of

the wax rim both on the right and left sides. On the maxillary rim in
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the corresponding areas cut two or three notches. This surface

should be slightly lubricated with petrolatum.

The maxillary base is placed in the mouth along with the

mandibular base. It is essential to remove any posterior recording

base interference. The recording base is held firmly to the lower

jaw, and the patient is instructed to close slowly and gently on the

back teeth under the guidance of the dentist.

Learned Position of Centric Relation

When you are satisfied that the patient can close in centric

relation, remove the mandibular base. Soft aluwax (Aluwax Dental

Products Co, Grand Rapids, Michigan) is placed in the areas from

which you removed 3-mm of wax rim. The Aluwax should be about

mm above the original height of the rim. The mandibular base is

then placed in warm water so that the wax on both the right and left

sides is evenly and thoroughly softened.

The base is placed in the mouth carefully and is completely

seated over the ridge; the patient is guided in retruding the jaw and

closing slowly with minimum force. The amount of closure is

critical and only the soft wax should come in contact with the

maxillary occlusion rim. In other words, the closure should continue

until the anterior occlusion rims are almost but not quite, touching;

that is, to within mm of the original accepted occlusal vertical

dimension. Remove both bases from the mouth. The Aluwax is

trimmed buccally and lingually. The bases are returned to the mouth,
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the jaw retruded, and closure made to see if the bases contact

simultaneously and in proper position. If this occurs, the record is

acceptable. If not, procedure is repeated until it is acceptable.

7. Inter Occlusal Centric Relation Records

Materials that are commonly used include plaster [fig:8],

wax, zinc oxide-eugenol (ZOE) paste, and cold-curing acrylic

resins. The patient closes into the recording medium with the lower

jaw in its most retruded position and stops the closure at a

predetermined vertical relation.

8. Other Methods of Recording Centric Relation

Some have been made by adjustment of the occlusion rims until

they contact fairly evenly in the mouth at the desired vertical

relationship.

Another method of obtaining records with wax occlusion rims is

to heat the surface of one of the rims and have the patient close

into this softened surface to make a new maxillo mandibular

relation impression.

Another method utilizes softened wax placed over the occlusal

surfaces of the posterior mandibular teeth.

One technique uses soft cones of wax to record CR.

Meyers 1934 used soft wax on the bite rims to establish a

Generated Path.

CONCLUSION
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To record centric relation is the most important step in

construction of complete denture. So we should take excessive care

in maintaining this till we deliver the dentures.

Fig : 1 Needle House Method

Fig : 2 The Patterson occlusion Rims. Pumice and plaster

Fig : 3 Ney mandibular excursion guide

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Fig : 4 Intra oral tracers

Fig :5 Extra oral tracers Fig : 6 Extra oral tracers in

patient

Fig : 7 Extra oral tracing Fig : 8 Intra oral record

REFERENCES
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Anderson JD. Biological and clinical considerations in making

jaw relation records and transferring records from the patient

to the articulator. In: Zarb GA, et al, editors. Prosthodontic

th
Treatment for Edentulous Patients. 12 ed. [Link]: Mosby;

2004. p. 268-297.

Heartwell CM, Rahn AO, editors. Textbook of Complete

Dentures. 5 t h ed. Canada: B.C. Decker; 2002. p. 275-301.

Sharry JJ. Intermaxillary Relations. In: Sharry JJ, editor.

Complete Denture Prosthodontics. 3 r d ed. New York: McGraw

Hill; 1962. p. 211-240.

Winkler S, Bailey R. Recording Edentulous Jaw

Relationships. In: Winkler S, editor. Essentials of Complete

Denture Prosthodontics. 2 n d ed. USA: Ishiyaku Euro America

Inc; 1996. p. 183-201.