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CENTRIC RELATION: CONCEPTS

AND CONTROVERSIES
[Type the document subtitle]

CONTENTS

Introduction
Terminology
Definition of Centric relation
Anatomic Vs Significance based definition
Chronology of change of definition of centric relation
Interpretation of definition of Centric relation
Anatomy of Temporomandibular joint as it pertains to centric relation
Important features of Centric relation
Significance of Centric relation
How Centric relation is acquired from birth?
Concepts of centric relation position
Centric relation and Condylar movement
Centric relation and Centric Occlusion
Review of Literature
Summary
Conclusion









INTRODUCTION

One of the objectives of Prosthodontics is to restore missing dental and oral
structures in such a way that there is a harmonious relationship among teeth,
bones, joints and muscles. One of the most controversial aspects of this complex
relationship has been referred to as centric jaw relation.

The term centric has been known in dentistry for many years and no other word
in dentistry has been a source of controversy for years together, as has been the
term centric. This term is derived from the word centre or centre oriented
relation. A number of workers in the past have provided us with many different
views about this seemingly complicated entity.

The importance of centric relation in complete denture prosthodontics has been
well known for many years. Some dentist claim that a correct centric relation is
the single most important measurement made in the construction of complete
dentures. The human mandible can be related to the maxilla in several positions
in the horizontal plane. Among these, centric relation is a significant and
important position. This is because of its usefulness in relating the dentulous or
edentulous mandible to the maxilla, where the teeth, muscles and the TMJ
function are in harmony. In other words, it is a position of occluso-articular
harmony.

The word centric is an adjective that should not be made to function as a noun.

TERMINOLOGY

Maxillomandibular relationship:
Any spatial relationship of the maxilla to the mandible; any one of the infinite
relationships of the mandible to the maxilla(GPT-8).

Terminal hinge axis /transverse horizontal axis:
An imaginary line around which the mandible may rotate within the sagittal plane
(GPT-8).



Terminal hinge relation
This is the range of retruded mandibular opening and closing movements while
the transverse axis remains constant to the glenoid fossa and the condyle. This
can happen only if the mandibular movement is of a pure hinge nature.



However, a pure hinge movement of the condyle occurs only when the mandible
is in its retruded position. This means that in centric relation, a pure hinge
movement occurs without translation of the condyle. Translation or combination
of translation and hinge movement occur only when the condyle shifts anterior to
centric relation. For this reason centric relation is known as the terminal hinge axis
relation.

In centric relation, condyles rotate in fixed axis. As long as that rotational axis stays
fixed at the most superior position against the eminentiae, mandible can open or
close and still be in centric relation. If the condyle axis moves forward, it is no
longer in centric relation.


Retruded contact position
That guided occlusal relationship occurring at the most retruded position of the
condyles in the joint cavities. A position that may be more retruded than the
centric relation position.

Centric occlusion
The occlusion of opposing teeth when the mandible is in centric relation. They
may or may not coincide with the maximum intercuspal position (GPT-8).

Maximal intercuspal position
The complete intercuspation of the opposing teeth independent of condylar
position, sometimes referred to as the best fit of the teeth regardless of the
condylar position, also called as maximum intercuspation.

Centric relation record
A registration of the relationship of the maxilla to the mandible when the
mandible is in centric relation. The registration may be obtained either intraorally
or extra orally.


DEFINITION OF CENTRIC RELATION
Apart from the extensive research in the field of centric relation, also unusual is
the change that centric relation definitions have undergone.

There have been six updates since its first publication in the Journal of Prosthetic
Dentistry (Glossary of Prosthodontic terms, 1956).
According toGPT 1-
The most retruded relation of mandible to maxilla 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.

Centric occlusion: Not defined

According to GPT 3
The most retruded physiologic relation of the mandible to the maxilla to and from
which the individual can make lateral movements. It is a condition that can exist at
various degree of jaw separation. It occurs around the terminal hinge axis.

The most posterior relation of the mandible to maxilla at the established vertical
relation.

Centric occlusion: The centered contact position of the lower occlusal surfaces
against the upper ones; a reference position from which all other horizontal
positions are eccentric.

According to GPT 4
The jaw relation when the condyle are in the most posterior unstrained position in
the glenoid fossae at any given degree of jaw separation from which lateral
movement can be made.

Acc to GPT 5
The maxillomandibular relationship in which the condyle articulate with the
thinnest avascular portion of their respective disks with the complex in the
anterior superior position against the slopes of the articular eminences. This
position is independent of tooth contact.
This position is clinically discernible when the mandible is directed superiorly and
anteriorly. It is restricted to purely rotatory movement about the horizontal axis.

Centric Occlusion: The occlusion of opposing teeth when the mandible is in centric
relation. This may or may not coincide with maximum intercuspation position.

Acc to GPT 8
Same as GPT-5 + additional 6 definitions

By Boucher (GPT 8) -
The most posterior relation of the lower jaw to the upper jaw from which lateral
movements can be made at a given vertical dimension.

By Ash (GPT 8) -
A maxilla to mandible relationship in which the condyle 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 (upto 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

By Ramfjord (GPT 8) -
A clinically determined position of the mandible placing both condyles into their
anterior uppermost position. This can be determined in patient without pain or
derangement in the TMJ.

By Lang (GPT 8) -
The relation of the mandible to the maxilla when the condyles are in the upper
most and the rearmost position in the glenoid fossae . The position may not be
recorded in the presence of dysfunction of the masticatory system

THE GLOSSARY OF OCCLUSAL TERMS INTERNATIONAL ACADEMY OF GNATHOLOGY
1979:
Centric relation:
The relation of mandible to maxilla when condyles are in their rearmost,
uppermost, midmost position in the glenoid fossa.

Centric relation can exist over a range of jaw opening and is not violated until the
condyle leaves their posterior positions in the glenoid fossae, the unstrained hinge
position of the mandible.


CONTROVERSIES REGARDING CENTRIC RELATION
Anatomical Vs Significance based definition

The two definitions of centric relation from the GPT 4 and GPT 5 appear to
contradict each other. The earlier definition mentions of a most posterior position
of the condyles in the glenoid fossa, while the latter definition speaks of an
anterior-superior position of the condyle against the slopes of the articular
eminence. Surprisingly the discrepancy between RUM position and anterior
position is only approximately 0.2 mm. Theoretically, the difference is only about
condylar position of centric.

Centric is better defined as When it is required to select one mandible to maxilla/
condyle fossa relationship that is most conducive to comfort, function and health
of odontostomato-gnathic system, then without any controversy it would be
centric relation position.
This is the functional definition of centric relation which gives an indication as to
why centric is important.

The GPT definition is purely a morphological definition, which purely describes the
location of condyle in centric which is controversial.The morphological definition is
only a guide to indicate the status of the condyle and to support the functional
definition of centric.

Centric relation is easily understood if functional definition precedes the
morphological definition.

Functional tells us Why centric is necessary
Morphological helps us to secure this functional position.

CHRONOLOGY OF CHANGE DEFINITIONS OF CENTRIC
RELATION
Mc Collum (1920) - rearmost condylar position

He showed that the condyle had a pure rotational movement when the operator
guided the mandible in the most retruded position in the glenoid fossa. He was
the first to name this position as centric relation.





Fig1: Diagram showing condyle in the rearmost position in the glenoid fossa

Granger (1962)- upmost ,rearmost position .
A second component namely a most superior position was considered necessary
for bracing since the condyle was unstable when it was only in the most posterior
position .






Fig. 2: Diagram showing the condyle in the uppermost, rearmostposition in the
glenoid fossa

Stuart (1969)- Rearmost ,uppermost, midmost condylar position-(RUM) position
A medial component was added for a stable condylar position (three
dimensional position). It was considered a physiological condylar position
harmonious with centric occlusion. RUM position was later accepted by the
International Academy of Gnathology.

American Equilibrium Society (1977)-
It challenged RUM position as it was considered to give pressure on the retrodiscal
tissue at bilaminar zone and proposed the most anterior and upper most position
of condyle opposite the slope of articular eminentia.

Celenza(1978)
Stated that condyle disk assembly braced superiorly and anteriorly against the
posterior slope of articular eminence.

American equilibration society (1987)
They revised their previous definition and believed that the condyle articulate
with the thinnest avascular portion of the disc in the anterior, most superior
position of the dorsal slope of eminence.

GPT 5 (1987)-
The maxillomandibular relationship in which the condyle articulate with the
thinnest avascular portion of their respective disks with the complex in the
anterior superior position against the shapes of the articular eminences.

New anterior superior definition

GPT 7 (1999)-
6 other definitions came along with it.

Whatever may be the difference in opinion regarding the precise location of
condyle in glenoid fossa, clinically centric relation is farthermost, retruded position
taken by the mandible without producing signs of strains on the
temporomandibular ligament.

This is the functional position of mandible at centric relation condition.

Position of condyle in glenoid fossa when this functional position is reached
CONTROVERSIAL

Controversies are:
Most superior position
Most retruded superior position
Most anterior superior position

The controversy regarding the most physiologic position of the condyles will
continue until conclusive evidence exists that one position is more physiologic
than the other.



INTERPRETATION OF DEFINITION
Understanding various terms used in definitions

The rearmost position is relative term which denotes that the condyles can
go backwards as far as the temporomandibular ligaments would permit
without any strain.

It does not literally means the most retruded position in the glenoid fossa,
since such a position will produce considerable amount of strain in
ligaments and cause pain.

The term Unstrained refers to strain of the ligaments and not the strain of
the muscles since its the ligament which limits the mandibular movements
and not the muscles and hence only ligaments can suffer strain if the head
of the condyle is taken posteriorly beyond centric relation position.Many
assume and believe that it is the strain of the muscles which retrude the
jaw. This is not true. During normal contraction of muscle, strain always
occurs. The closing and retruding muscles are under some degree of strain
in centric relation as centric is a power position. Rest position of the jaws is
the only position where there is minimum tonic contraction of the muscles
and truly an unstrained position.

Centric relation is the most distal position of the head of the condyle
without causing strain on the ligaments.

The most anterior superior position of the condyle is the position used by
the head of condyle when the mandible is in its retruded position, from
where there is an anterior superior bracing of condyle against the distal
slope of articular eminence.
Anterior superior bracing against the distal slope of articular eminence is an
intra articular position which cannot be clinically visualized.

Analysis of GPT-1 definition

GPT 1 defines centric relation as the most retruded unstrained position of
condyles in the glenoid fossa at any given degree of jaw separation from which
lateral movements can be made.
It is divided into three parts:

1. It is the most retruded unstrained position of the condyles in the glenoid
fossa.
This is included in definition since this position is constant and can be
recorded as it is desired throughout the life.
No other position anterior to this can be recorded twice.
Since the individual assumes this most retruded position voluntarily by the
action of his mandibular musculature, this position is unstrained.

2. .at any given degree of jaw separation
This implies that centric relation can be recorded in any vertical position of
the mandible from one of the extreme overclosure to one of overopening.

3. from which lateral movements can be made
This implies that it is impossible for individual to make lateral movements
when mandible is opened to its greatest extent and that there must be no
`forced` retrusion- a point from which the individual can certainly make no
movements.

Centric relation
JPD 1952
However Granger in 1952 called this definition of centric relation as inadequate
since it fails to consider the axial relationship, which is the only reason for the
importance of centric relation.

According to him any given point on the surface of the head of the condyle does
not remain in fixed relation to the meniscus. In every position however, the hinge
axis does remain in same relation to the meniscus. And the only position in which
it is possible to locate and reproduce the hinge axis is centric relation.

Therefore centric relation is the terminal hinge position of the mandible, in which
hinge axis is constant to both maxilla and mandible.

Analysis of CR definition by Dawson
Dawson has interpretated the definition of centric relation by dividing it into 5
parts:

The relationship of the mandible to the maxilla/ when properly aligned condyle-
disk assemblies/ are in most superior position/ against the eminentiae/
irrespective of the vertical dimension or tooth position.

1. The relationship of maxilla to mandible...
Importance of determining correct maxillomandibular relationship before
analyzing and planning treatment enables us to know the importance
properly mounted diagnostic casts.

Since centric relation is mandible to maxilla/ relationship that is most
conducive to comfort, function and health of odontostomato-gnathic
system, casts mounted in centric relation enables us to accurately
determine what must be done to bring the teeth into this harmony.
Ignoring the position of TMJ when examining the occlusion is not
acceptable.Just putting the cast together in maximum intercuspation does
not provide the necessary information on how mandibular teeth relate to
maxillary teeth when condyles are in CR position. Nor does it show what
must be done to achieve harmony between occlusion and TMJ.

Analysis of mandible to maxilla when condyles are in CR presents a
completely different picture from maximum intercuspation.Now it becomes
obvious why molar are loose or wearing excessively? If TMJ in not in CR
they cannot accept firm loading with complete comfort.

2. properly aligned condyle-disk assembly...
If condyle is off the disk, upward pressure loads the condyle directly onto
the vascular, innervated tissue and cause a response of tenderness or pain.


3. against the eminentiae
TMJ = Hanging joints that should not be subjected to loading forces
because they overly compress the joint structures is a MISCONCEPTION.
Rather contraction of the elevator muscles keep condyle-disk assemblies
loaded throughout the functional movements. Hence TMJ are Load
bearing joints. Also this is against the eminentiae because when all the
elevator muscles contract to pullthe mandible towards the origination of
each elevator muscle, the condyle will be pulled tightly against the
eminentiae.This is how the muscle always works by shortening their length
to pull the attached bone towards the site of muscle origin.

4. irrespective of tooth position or vertical dimension
This implies that if the condyles are in centric relation, they can rotate on a
fixed axis to an opening of 20mm. Thus a bite record made at any point of
opening on the correct CR arc is still in centric relation.If the casts are
mounted on an articulation with correct condylar axis, the vertical
dimension can be increased or decreased without any error.
Thus the false conclusion that condyles cannot rotate on a fixed axis has led
some clinicians to discredit the face bow recordings and articulators,
claiming that the vertical dimension cannot be accurately changed on an
articulator.. A provably false belief.

5. most superior position
Most important condition to understand about CR is that in centric relation,
the properly aligned condyle-disk assemblies are completely seated in the
most superior position in their respective sockets.

ANATOMY OF TMJ AS IT PERTAINS TO CENTRIC RELATION


Cross-section of the Temporomandibular Joint

Temporomandibular Joint
It is the articulation between the temporal bone and the mandible.
The major components of the temporomandibular joint are the cranial base, the
mandible and the muscles of mastication with their innervations and nerve
supply. An articular disk separates the mandibular fossa and articular tubercle of
the temporal bone from the condylar process of the mandible.



The compound synovial joint occurs between the squamous part of temporal
bone and the mandibular condyle. A complete intra articular disc separates the
two bones, matches the contour of their articular surface and subdivides the joint
space into two synovial compartments.

Upper compartment: Arthroidal / gliding joint: Between the mandibular
fossa and condyle-disk assembly.
Lower compartment: Ginglymoid/ hinge joint: Between Condyle and
articular disk


Compartments of the temporomandibular joint

Inferior compartment: Joint is pure ball and socket joint. Since disc is tightly
bound to condyles by lateral and medial discal ligaments the only
movement possible is rotation.
Superior compartment: Lateral movements are accomplished by the sliding
ball and socket joints as a unit on the glenoid fossa.This is because disc is
not tightly attached to the articular fossa, so free sliding movements is
possible between these surfaces Translation.In use, these two
movements always occur simultaneously, however one joint may describe
the gliding and rotational movements while other only rotational
movements.

The centre of rotation
In each of these rotatory movements, the condyle moves or rotate about an
axis.In pure vertical motion it revolves about a horizontal axis, in pure horizontal
rotation it revolves about a vertical axis. In intermediate rotation it revolves about
an axis at right angles to plane of rotation. All these axis meet at a point within the
condyle. This is Centre of rotation.


When these points in two condyles are connected by an imaginary line, it forms
HINGE AXIS.

Since hinge axis is located within the condyle, during any bodily movements of the
mandible the hinge axis move along with it. If mandible is protruded by moving
the meniscus upon the glenoid fossa, the hinge axis remains in same relation to
the meniscus but not to the glenoid fossa. So hinge axis is said to be constant to
the mandible.There is however, one and only one position in which hinge axis is
constant to both mandible and maxilla. This is centric relation position.

In Centric relation position, mandible is opening and closing with pure rotatory
movements in vertical plane around the hinge axis.Purely rotational movement,
around the horizontal axis till the patient opens his mouth to about 20-25mm.This
axis is called TERMINAL HINGE AXIS.Since this axis is constant to the mandibular
teeth in every eccentric position and constant to both mandible and maxilla in
centric relation, the axial relation of the teeth will be correct in every mastication
procedure.The only position of the mandible in which pure rotatory movement
can occur is that in which the meniscus is in the tough of the fossa, in the most
retruded position to which it can be carried by patients own musculature.

GLENOID FOSSA
The mandibular condyle articulates at the base of the cranium with the squamous
portion of the temporal bone.This portion is made up of Concave Mandibular
Fossa called as ARTICULAR OR GLENOID FOSSA.


SQUAMOTYMPANIC FISSURE Posterior to mandibular fossa.
Anterior to fossa convex bony prominence called ARTICULAR EMINENCE.
Structure of the glenoid fossa

Anterior portion: This portion of the fossa is the principle bearing surface
upon which the condyle presses through the disk and other structure.

Posterior portion: This portion of the fossa is more nearly perpendicular.
The condyle does not bear directly in the fossa because it is separated by
the synovial membrane and the articular disc.
Middle part of the fossa is a fairly thin plate of bone whose upper surface
forms the middle cranial fossa.


Immediately anterior to the fossa is a convex bony prominence called the articular
eminence.

The degree of convexity of the articular eminence is highly variable but
important because the steepness of the surface dictates the pathway of the
condyle when the mandible is positioned anteriorly.
The posterior roof of the mandibular fossa is quite thin indicating that this area
of the temporal bone is not designed to sustain heavy forces.
The articular eminence however consists of thick dense bone and is more likely
to tolerate such forces.

ARTICULAR DISC
Articular disc is composed of dense fibrous connective tissue devoid of nerves and
blood vessels. This allows it to withstand heavy forces without damage or
inducement of painful stimuli.The purpose of this disc is to separate, protect, and
stabilize the condyle in the mandibular fossa during functional movements.



In SAGITTAL PLANE it is divided into 3 regions (according to thickness).
1. Anterior
2. Posterior zone
3. Intermediate zone
Posterior border is slightly thicker than anterior border; intermediate is the
thinnest area of the disc.



LIGAMENTS OF THE JOINT
Ligaments do not enter actively into joint function but instead act as passive
restraining device to limit or restrict border movements.

These include:
Collateral (Discal) ligaments: They function to restrict the movement of the
disc away from the condyle. So they permit the disc to be rotated anteriorly
and posteriorly on the articular surfaces of condyle, hence responsible for
hinging movement of temporomandibular joint.


Capsular ligament: This ligament acts to resist any medial, lateral or inferior
forces that tend to separate or dislocate the articular surfaces.


Temporomandibular ligament: It is composed of two parts : Outer oblique
part which resists excessive dropping of the condyle, therefore limiting the
extent of mouth opening. It also influences the normal initial phase of
opening, when condyle rotates around a fix point until this ligament becomes
tight.

Beyond this if mouth is to be opened, the condyle needs to be moved downward
and forward across the articular eminence.


In the erect posture and with vertically placed vertebral column, continued
rotational movement can cause the mandible to impinge on vital submandibular
and retromandibular structures of the neck. The outer oblique portion of TM
ligament resists this impingement.


The inner horizontal portion of the TM ligament limits posterior movement of
condyle and disc thereby preventing trauma to retrodiscal tissues.

Stylomandibular ligament : It limits excessive protrusive movements of the
mandible.


ROLE OF MUSCULATURE
Positional stability of the temporomandibular joint is determined by the muscles
that pull across the joint and prevent dislocation of the articular surfaces. The
directional forces of these muscles determine the optimum orthopedically stable
joint position.

The major muscles that stabilize the joint are the elevators.

Muscles of mastication involved in centric positioning
Temporalis
The functions of the posterior part of these muscles are to retrude the mandible
and brace the condyle during lateral mandibular excursions.

The function of the middle parts is to elevate the mandible into centric position.

Masseter muscle
The principle function of the masseter is to elevate the mandible vertically in
order to obtain maximum intercuspation. The deep portion of the masseter
muscle helps to retrude the mandible.

Medial pterygoid muscle
It is similar to the superficial masseter in fiber direction, and these two muscles
function synergistically to form the muscular sling.

Lateral pterygoid muscle
Besides its important role in opening of the jaws and protrusion of the mandible
lateral pterygoid also has an important role in determining the position of the
condyles relative to the eminence, and limits the degree of condylar retrusion.

Inferior lateral pterygoid muscle positions the condyles anteriorly against the
posterior slopes of the articular eminences.

Superior lateral pterygoid remains inactive during mouth opening, it becomes
active only in conjunction with the elevator muscles. These muscles are primarily
responsible for joint stability and position.

RELOCATION OF CENTRIC RELATION POSITION OF THE
CONDYLES FROM RUM TO THE ANTERO-POSTERIOR
POSITION

The main reasons for the shift in focus from the rearmost, upmost and midmost
position of the condyles to the anterosuperior position are as follows:

The roof of glenoid fossa is extremely thin and translucent. There is no
articular cartilage in the glenoid fossa, with minute foramina for the
passage of blood vessels and nerves. The thickened posterior zone of the
articular disc occupies the glenoid space. This portion contains blood
vessels and nerves and therefore is not suited for function of articulation.
On the other hand, the superior portion of the condylar head is covered
with articular cartilage extending forward over the anterior face of the
condyles and is designed for stress.
Similarly, the bony trabeculae on the curved surface of the posterior
portion of the eminentia are oriented parallel to the direction of the
articular eminence to withstand stress.
The center of the articular disc that is interposed between the condyle and
the posterior slope of the articular eminence is devoid of nerves and blood
vessels, indicating a stress bearing portion of the functional area of the disc.
On the other hand, the non-stress bearing thick periphery of the disc is rich
in blood vessels and nerves.
The disk is thickest posteriorly (2.9 mm) and thinnest in the middle part
(1mm).

Hence the posterior portion of the eminentia articulating with the thin
intermediate zone of the articular disc opposed by the anterior face of the
condylar head appears to be the most logical functional arrangement for centric
positioning of the condyles.

Thus the RUM position is not physiological to joint and superior anterior bracing of
the condyle disc assembly against the slope of eminentia was the optimum
condylar position in centric (Celenza, 1973).

IMPORTANT FEATURES OF CENTRIC RELATION

It is the ideal arch-to-arch relationship and hence optimum position of jaws
for the health, comfort and function of the TMJ.

It is a retruded mandible position where the condyles are situated
anterosuperiorly in the glenoid fossa as far as the ligaments of the TMJ and
musculature would permit.

It is a reproducible position, which can be repeatedly arrived at and thus
serves as a reliable guide to develop centric occlusion in artificial dentures.
It is a starting point for the arrangement of artificial teeth to develop
maximum intercuspation in complete dentures.

It also serves as a reference position for the institution of occlusal
rehabilitation in dentulous conditions.

It serves as a reference position to relate and nomenclate several occlusal
positions of upper and lower teeth.
The terminal position of masticatory stroke end in centric relation. It is also
a position where upper and lower teeth are braced against each other
during deglutition.

It is a relationship of mandible to maxilla when both the condyles are in
terminal hinge location. It is a position of terminal hinge closure.

SIGNIFICANCE OF CENTRIC RELATION
Correct registration of centric relation is essential in construction of complete
dentures. Many dentures fail because the occlusion is not planned or
developed in harmony with this position.
The maxillo- mandibular musculature is so arranged that a patient can easily
move his mandible into centric relation. Thus CR serves as a reference
relationship for establishing an occlusion. When the CR-CO of artificial teeth
do not coincide or a freedom in centric is not present, the stability of the
denture bases is in jeopardy and the edentulous patient is subjected to
unnecessary pain or discomfort.
Components of the masticatory system are the functional unit. In edentulous
subjects the dental components are lost. Dentures restore the masticatory
functioning, phonetics provided they are made at specific vertical and
horizontal relation of the mandible to the maxilla. Unless these relations are
properly ascertained, recorded and transferred to the articulator, the
prosthesis may fail.The human mandible can be related to the maxilla in
several positions in the horizontal plane. Centric relation relates the dentulous
or edentulous mandible to maxilla in a position when teeth, muscles and
temporomandibular joint function in harmony. It is a position of occluso-
articular harmony.
CR is the horizontal reference position of the mandible that can be routinely
assumed by edentulous patients under the direction of the dentist. This makes
it possible to verify the relationship of casts on the articulator when they are
mounted in Centric Relation.
Patients use CR closures in mastication and other activities, such as
swallowing. When a bolus a food is prepared for swallowing, the teeth
attempt to masticate it so that it has a semi fluid consistency as it passes into
the esophagus. To do this, it is necessary to apply strong muscular force
against the bolus. At this time, the condyles follow the paths of movement
that the anatomic structure of the joint dictates, i.e., in an upward and
backward direction. The condyle tries to seat itself in the glenoid fossa as far
as it will go by its own muscular power. If the teeth intervene before this
position is reached, there is a lateral component of force registered upon the
teeth which subsequently causes pain in temporomandibular region.

The degree of this lateral force is directly proportional to:
1. The amount of force applied by the muscles of mastication
2. The degree the jaw is out of centric relation.

This signifies importance of accurate centric relation recording. Therefore the
casts must be mounted on the articulator in this position so that the opposing
teeth on complete dentures will meet evenly when the patient closes in CR.

Cohen;JPD; 1960; 10; 248
Why is it that not all patient whose centric relation and centric occlusion are
inharmonious are not heir to all the pathologic changes attributed to this
condition?

There are several reasons:

The degree of tolerance in joint which permits the condyle to be out of its ideal
position in final closure of mandible.
Morphologic point of view, there are three types of glenoid fossa :

Type 1 anterior slope of the fossa is very light. Not much lateral component
of force on the teeth or a pressure on the border of the meniscus .This type of
joint has the greatest degree of tolerance.



Type 2 this is most generally encountered. The anterior wall has
approximately a 30 degree inclination to the axis orbital plane. This joint has
little tolerance.


Type 3 found occasionally. It has a very steep anterior wall and has no
tolerance. This type of joint causes the most trouble since any slight
eccentricity of the maxillomandibular relationship causes a pressure on the
borders of the meniscus.


Granger. JPD; 1952; 2; 160
He stated that centric relation is the terminal hinge position of the mandible
which establishes the relation of the axis of the condyles to the teeth as they will
close with muscular force against the resistance of a bolus of food in every
contacting position.

As the teeth meet, they interdigitate, and pressure is exerted along their long axis.
The hinge axis determines the arc on which they close and is related to the curve
of the cusps. In the case of full dentures the proper centric closure seats and
holds the denture firmly in place.

CR must be recorded correctly to permit accurate adjustments of the condylar
guidance of the articulation for other eccentric movements. Condylar guidances
are adjusted to form a pathway of condyle movement from a beginning point to
the position of eccentric occlusal record. CR is the accurate beginning point for
these other articulator adjustments.

HOW CR IS ACQUIRED FROM BIRTH?

Centric relation is learned after the teeth erupt. It is the first learned reflex
determining the occlusal position of the mandible after the primary dentition
is complete. Eccentric mandibular positions are learned as expedient
mechanisms for avoiding occlusal disharmonies.

The mandible is moved and supported by a group of muscles, most of which
receive their innervations from the fifth cranial nerve. They are classic
examples of antigravity muscles.

When all the muscles capable of moving the mandible demonstrate no
contractions other than those necessary to hold the bone in a balanced
position against gravity, a state of equilibrium is maintained. The physiologist
calls this the postural position of the mandible. The dentist calls it the
physiologic rest position of the mandible.

Only this postural position is consistently observed prior to the eruption of the
teeth. An occlusal sense develops as the erupting primary teeth first meet
their antagonists of the opposite jaw. This occlusal sense is the formation of
the neuromuscular reflex establishing centric relation.

After the teeth have erupted, the muscles learn one position of occlusion
providing a maximum of occlusal contact and minimum of torque or lateral
stress and strain on the roots of the teeth. This is the beginning of centric.

At the beginning, centric relation and centric occlusion are identical. Centric
relation is the first established neuromuscular reflex concerning mandibular
position when the teeth are in occlusion.

The anteroposterior limits of centric relation are defined first, since the
primary incisors erupt first and restrict mandibular movements in this one
direction only. Later, the teeth in the lateral segments of the dental arch inhibit
mediolateral positioning, and thus help localize the limits of centric relation in
this other direction. The vertical limits of centric relation are never so precisely
defined.

CONCEPTS OF CENRTIC RELATON POSITION

There are two concepts: Douglas Allen Atwood , JPD ;1968;20 ;21
Anatomic
Pathophysiologic

Anatomic: Centric relation is most retruded relation. A border position
determined by the ligaments.
Pathophysiologic: Centric relation is the most posterior unstrained jaw relation
. A position which is not a border position and is established by muscle action .

S. David and R.M.J Gray; 2001; BDJ; 191; 235.
Described centric relation three different ways ,
1. Anatomically
2. Conceptually
3. Geometrically

Anatomically describe centric relation as position of the mandible to the
maxilla with the intra-articular disc in place, when the head of the condyle is
against the most superior part of the distal facing incline of the glenoid fossa.

The bone and fibrous articular surfaces are thickest in the anterior aspect of the
head of the condyle and the most superior aspect of the articular eminence of the
glenoid fossa.

Conceptual describes centric relation as that position of the mandible relative
to the maxilla, with the articular disc in place, when the muscles that support
the mandible are at their most relaxed and least strained position.
This definition supports the concept of a qualitative relationship between a jaw
position and another element of the articulatory system.


Geometrical described centric relation as position of the mandible relative to
the maxilla, with the intra- articular disc in place, when the head of the condyle
is in terminal hinge axis.
Mandible opens firstly by a rotation of condyle and then a translation.
Therefore, while closing in terminal closure it is purely rotational.
At this phase of closure the mandible is describing a simple arc, because the
centre of its rotation is stationary. This provides the terminal hinge point (of
rotation) of one side of mandible; but because the mandible is a bone with
two connected sides these two terminal hinge points are connected by an
imaginary line:the terminal hinge axis.

CENTRIC RELATION AND CONDYLAR MOVEMENT

Anatomic mechanism of the centric relation is unknown.

Several theories have been given , the most accepted ones are :

THE MUSCLE THEORY
THE LIGAMENT THEORY
THE OSTEOFIBER THEORY
THE MENISCUS THEORY

THE MUSCLE THEORY
According to this theory, the centric relation is considered to be product of a
defense reflex which causes the external pterygoid muscle to contract and
thus halt the jaw every time the condyles or the interarticular disc approach
the posterosuperior depth of glenoid fossae.

DRAWBACKS
It could not explain the fact that centric relation is always the same at any
vertical level.
No anatomic explanation is provided for the posterior hinge movement, nor for
the acuteness of the needle point tracing .
If external pterygoid muscles were responsible for CR, the hinge axis would
then go through anterior cervical insertion of these muscles, which it does not
do, and needle point tracing would be elliptical.
Woelfel, Hickey and Rinear found that the external pterygoid muscles are
relaxed when the mandible is in centric.

THE LIGAMENT THEORY
Given by Ferrein
Acc to this theory, when the ligaments become tense they determine the
limits of the retrusive movement. They are also capable of determining the
terminal border movements.

When condyle within glenoid fossa is fully retracted, retrocondylar space
behind it can be observed. It is possible to insert a surgical instrument in
front of the tympanic plate and touch the posterior glenoid roof without
disturbing the condyle from retruded position.Therefore the posterior wall
of glenoid fossa does not constitute the condylar stop.

When condyles in centric relation are seen in lateral radiograph , it appears
to be suspended or floated. These views reinforce the theory that soft
radiographically translucent tissue is determining the final condylar
position, and TMJ ligament are fulfilling these condition.The
temporomandibular articulation in centric relation.


However, Ferrin, Posselt and Arstad found in cadavers, that
temporomandibular ligament were tense when the jaw is in terminal
retruded position.

DRAWBACKS
The ligamentous fibers and the direction of the condylar sagittal path form
an angle of almost 90 degree. This anatomic arrangement of
temporomandibular ligament is not suited to halt the retrusive condylar
movement.
Ligamentous retrusive terminal stop provides no satisfactory location of the
hinge axis.

Indeed, if the temporomandibular ligaments constitute the retrusive
terminal stops, the posterior hinge opening must have its axis formed by
the line connecting the ligamentous fiber insertions at the condylar necks.
Nevertheless, the hinge axis appears to be centrocondylar .(Saizer and
Rothman;McCollum)

Boucher (JPD, 1961, 11, 23)
He found that the centric relation mandibular position does not change in the
cadaver after section of the capsular ligament.

This theory does not explain satisfactorily the lateral border movements, because
it cannot produce an acute gnathographic angle.It registers an elliptical tracing.

THE OSTEOFIBER THEORY
Given by Meyer.
Acc to this theory, a retrusive terminal stop is formed by the soft tissue
of the posterior part of the roof of the glenoid fossa.
These fibrous stop acts as a buffer.

DRAWBACK
Sicher(1965) pointed out that there is a thick layer of loose and
vascularized connective tissue posterior to the condyles. Such tissue is
readily adaptable to movement, either forward or backward.
Rather than being a protector, such tissue needs to be protected.

THE MENISCUS THEORY
Given by saizer
The articular disk has definite zones. The thinner centric bearing area and
the thicker anterior and posterior bands and the bilaminar zone.

The central bearing area of the inter-articular tissue remains interposed
between the condylar articular surface and the articular eminence during
simulated jaw movements.The bearing area is composed of densely woven
collagen fibrils having no vascularity or innervations which indicate that
zone is adapted to accept pressure.


Thickened posterior band possesses vascularity and innervations. Because
articular eminence is an inclined plane, condyle disk assembly must be
stabilized on this slope by muscular activity unless it is in a position of
muscular equilibrium.The posterior movement of condyle on the eminence
has been attributed to wedging of the thickened posterior band of disk
between the distal surface of the condyle and the roof of the articular fossa.




The innervated posterior band possibly protects (by sensory feedback) the
thin roof of the articular fossa from heavy pressure and provides a
biomechanically stable relationship. It appears that any position posterior
to this limit cannot be functional, as the condylar articular surface cannot
engage the central bearing area of the disk and the eminence; nor can the
position be biomechanically stable .



CENTRIC RELATION AND CENTRIC OCCLUSION

Centric occlusion (GPT 8) - the occlusion of opposing teeth when the mandible is
in centric relation.

The understanding of centric relation is complicated by failure to distinguish
between centric relation and centric occlusion.

Centric occlusion is a tooth-to-tooth position whereas centric relation is bone
to bone relation.
Centric relation serves as a reference position or baseline to nomenclate the
various occlusal positions. Both may or may not be identical to each other.

Numerous studies have reported that the majority of patients with a natural
dentition show discrepancy between the occlusal position of the mandible in CR
and MI. This discrepancy is present in atleast 90% of dentitions.

In person with natural teeth, both centric relation and centric occlusion
exist. After the removal of teeth, centric occlusion is lost, while centric
relation remains and serves as a reliable guide to develop centric occlusion
in artificial dentures.

In dentulous individuals, occlusion in centric relation (RCP retruded
contact position) is not and need not be centric occlusion, although it would
be ideal to have centric occlusion at centric occlusion.

In edentulous individuals however it is feasible that centric relation and
centric occlusion are made to coincide.

When centric occlusion does not coincide or is not identical with centric relation,
the condyles do not remain in their upper most position in the glenoid fossae, but
take a position either anteriorly or laterally. This referred as centric slide.

Clinically, the difference between the two occlusal positions can easily be
determined by closing the mandible in its CR position by manual guidance until
the first tooth contact is established. This used to be called the retruded contact
position (RCP) for many years and is now called centric relation contact position
(CRCP).


The significance of the discrepancy is based on the presence of premature
contacts, so that the patient is only able to find a stable occlusal position during
closure in centric relation by sliding into MI. Premature contacts in general, and
premature contacts during closing in CR in particular, might be trigger points for
para-functional activities like clenching and bruxism. When the intercuspation of
the teeth is in harmony with both correctly positioned and aligned condyle-disk
assemblies, centric relation and centric occlusion are the same. This is the goal of
occlusal treatment.

CENTRIC RELATION SHOULD COINCIDE CENTRIC
OCCLUSION

In natural dentition, tooth interferences in centric relation initiate impulses and
responses that direct the mandible away from deflective occlusal contacts into
centric occlusion.

Impulses created by the closure of teeth into centric occlusion establish memory
pattern that permit the mandible to return to this position without interferences.
When natural teeth are lost, many receptors that initiate impulses resulting in
positioning of the mandible are lost or destroyed.Edentulous patients cannot
control mandibular movements or avoid deflective occlusal contacts in centric
relation in the same manner as the dentulous patient can.

Deflective occlusal contacts in centric relation cause movement of denture bases
and displacement of supporting tissues or direct the mandible away from centric
relation . The centric relation must be recorded for edentulous patient so that
centric occlusion can be established in harmony with centric relation .

CR not in harmony with CO



When mandible is in CR, opposing tooth do not contact evenly.

CR is not harmony with CO

For opposing teeth to meet evenly as in CO, the mandible must be moved away
from CR

CR in harmony with CO



This can usually be achieved with centric relation and centric occlusion
coinciding.
In some patients a broader area of stable contacts near centric relation is
necessary ,which is called freedom of centric or long centric

Posselt and Glickman reported that maximal intercuspal relation of the teeth
is anterior to terminal hinge postion in 90% of analyzed individuals with full
complement of teeth.

Posselt (JPD 1971/25/12) - centric occlusion placed the mandible an average of
1.2 mm anterior to its position in centric relation.

Beyron (DCNA1971, 15, 4) only 10 % of the individuals the centric relation
and centric occlusion coincide. Centric occlusion occurs anterior to centric
relation at varying but short distance.

William E Avant (1971) when no occlusion of teeth (natural /artificial) is
involved then both centric relation and centric occlusion lose their significance.
Yahia H.Ismail (JPD 1980 ,43 , 327 ) in centric occlusion condyles were
centrally located antero-posterior in their fossae with equal anterior and
posterior joint spaces .


REVIEW OF LITERATURE

Centric Position
Robinson JPD; 1951; 1; 384
He stated that centric position is not only the maxillomandibular relation where
the teeth should occlude in normal or good functional situation, but also where
the condyle of mandible is in a balanced and unstrained position in the
mandibular fossa.
This position exists when the anterosuperior surface of the condyle is in close
approximation with the posterior-inferior surface of the articular eminence.

Centric relation
Granger. JPD; 1952; 2; 160
He stated that centric relation is the terminal hinge position of the mandible
which establishes the relation of the axis of the condyles to the teeth as they will
close with muscular force against the resistance of a bolus of food in every
contacting position.

As the teeth meet, they interdigitate, and pressure is exerted along their long axis.
The hinge axis determines the arc on which they close and is related to the curve
of the cusps. In the case of full dentures the proper centric closure seats and
holds the denture firmly in place.

Physiologic jaw relations and occlusion
Shanahan JPD; 1955; 5; 319-324
He stated the constant function of swallowing saliva is the basis for establishing
the mandibular positions and occlusion.

In swallowing saliva, the mandible rises to its habitual closing terminal, then, as
the saliva is swallowed mandible is forced backwards into the pharynx by the
tongue, thus retruded to its physiological centric relation.


Stuart JPD;1960;10;304
He stated that the success has been judged by how well the teeth close in centric
occlusion, how well they balance bilaterally and protrusively.

If the teeth passed these tests, the examiner would know that the total setup of
the cusps was identified with that basic jaw position called centric relation. Such
balanced occlusion cannot be attained if started from a mandibular occlusal
position not centrically related.
Hinge axis and its practical application in determination of centric relation
Cohen ;JPD;1960;10;248
The center of meniscus is devoid of blood vessels and nerves and is pressure
bearing. Due this fact every joint has a degree of tolerance which permits the
condyle to be out of its ideal position in final closure of mandible.

Morphologic point of view,there are three types of glenoid fossae.

Type 1 anterior slope of the fossa is very light. No much lateral component
of force on the teeth or a pressure on the border of the meniscus .this type of
joint has the greatest degree of tolerance.

Type 2 this is most generally encountered. The anterior wall has
approximately a 30 degree inclination to the axis orbital plane .this joint has
little tolerance.

Type 3 found occasionally. It has a very steep anterior wall and has no
tolerance. This type of joint causes the most trouble since any slight
eccentricity of the maxillomandibular relationship causes a pressure on the
borders of the meniscus.


Anatomy of TMJ as it pertains to centric relation
Jamieson ;1962;JPD;12;473
The indefinite apex of needle point tracing is often the result of degenerative
changes in the structure of the temporomandibular joint which permit a greater
latitude in movement. A degenerative change may occur in any part or all of the
neuromuscular mechanism.

The indefinite apex may be an indication of acquired habitual mandibular
movement which are the result of malocclusion of remaining natural teeth. Many
of these patients, when edentulous for a period of time and conditioned by
exercise of the muscles of mastication, will be able to produce more accurate
tracing.


Anatomy of TMJ as it pertains to centric relation
Boucher JPD; 1962;12;464
He stated that centric relation is controlled by neuromuscular reflex which does
not necessarily always function in the same anteroposterior position.

The terminal hinge position and the apex of the needle point tracings of the
retruded mandible may be desirable positions from which to start the
construction of dentures because they are reference positions, but this does not
imply that it may be the ideal functional position of the mandible for all patients.

Shahahan and Leff 1963;JPD;13;871
The theory that the mandible rotates about vertical axis in the region of condyles
during lateral movements was investigated using central bearing plates.

They concluded that use of a central bearing point produces unnatural influences
upon the lateral movements of the mandible.



Study of the mandibular movement from centric occlusion to maximum
intercuspation
Lester Clark JPD;1967;18;19
They concluded that:
The mean anteroposterior component of slide measured with a position
gnathometer was 0.440.54mm
The mean vertical component was 0.470.64mm
The mean lateral component of slide was 0.010.29mm

Radiographic study of condylar position in centric relation and centric occlusion
Yahia H Ismail; JPD;1980;43;327
He radiographically determined the spatial differences in the condyle-to-fossa
relationship when the mandible is in the centric relation and centric occlusions.

It was concluded that in centric relation position , both condyles were placed
more posteriorly and superiorly in their fossae than in centric occlusion
position .

In centric occlusion position , both condyles were symmetrically placed in their
fossae with equal spatial distance anteriorly and posteriorly.

Greater spatial difference existed between the centric occlusion and centric
relation positions on the left side , which was the orbiting (balancing ) side in
most subjects .

Dawson 1995;JPD;74;619
He defines adapted centric posture as the relationship of the mandible to maxilla
that is achieved when deformed temporomandibular joints have adapted to the
degree that they can comfortably accept firm loading when completely seated at
the most superior position against the eminentiae.

Like centric relation , adapted centric posture is a horizontal axial position of the
condyles. It occurs irrespective of vertical dimension or tooth contact .

It is also a midmost position, because even if the disk is totally displaced, the
medial pole of the condyle adapts to the concavity of the fossa and maintains
contact against its medial pole .


Condylar movement and centric relation in patients with internal derangement of
the temporomandibular joint.
Harper 1996;JPD;75;67
Based on his study he concluded that centric relation in normal TMJ include a
dynamic range of horizontal adaptation to the potential biomechanical and
biologic stresses related to oral function.

The centric relation position or deranged reference position of the condyle in
patient with TMJ internal derangement is a static position with decreased
potential for adaptation.



















SUMMARY

The term centric has been known in dentistry for many years and no other word
in dentistry has been a source of controversy for years together, as has been the
term centric.

The human mandible can be related to the maxilla in several positions in the
horizontal plane. Among these, centric relation is a significant and important
position. It is a position of occluso-articular harmony.

The two definitions of centric relation from the GPT 4 and GPT 5 appear to
contradict each other. The earlier definition mentions of a most posterior position
of the condyles in the glenoid fossa, while the latter definition speaks of an
anterior-superior position of the condyle against the slopes of the articular
eminence.
Functional definition tells us Why centric is necessary
Morphological helps us to secure this functional position.
Position of condyle in glenoid fossa when this functional position is reached
CONTROVERSIAL
Most superior position
Most retruded superior position
Most anterior superior position

Based on understanding of anatomy and biomechanics of TMJ it is presently
accepted that the RUM position is not physiological to joint and superior anterior
bracing of the condyle disc assembly against the slope of eminentia was the
optimum condylar position in centric.

Centric relation is a reference point for establishing the occlusion.
It is the most retruded position of mandible in glenoid fossa which is
reproducible and repeatable.

Centric relation can be described anatomically, conceptually and geometrically.

Anatomic mechanism of centric relation is explained through 4 theories : The
muscle theory, The ligament theory, The osteofibre theory & The meniscus theory.

Positional stability of TMJ at centric relation is determined by elevator muscles,
however it is the ligaments which act as passive restraining devices for the border
movements.

Centric relation is bone to bone relation, while centric occlusion is tooth to tooth
relation.

When the intercuspation of the teeth is in harmony with both correctly positioned
and aligned condyle-disk assemblies, centric relation and centric occlusion are the
same. This is the goal of occlusal treatment.












CONCLUSION
The term centric relation has been used in dentistry for many years. Although
it had a variety of definitions, it is generally considered to designate the
position of mandible when condyles are in the terminal hinge position. Centric
relation is the most reliable reference point obtainable in edentulous patient
for accurately recording the relationship between mandible and maxilla and
ultimate for controlling the occlusal contact pattern. The determination of
centric relation is rightly considered one of the most important steps in
complete denture construction.

It is apparent from the dental literature, that there are many opinions and
much confusion concerning centric relation records. In normal cases, the
occlusion, the temporomandibular joints, the bone, the soft tissue, and the
musculature all produce the same relation to each other and any one of the
many registration techniques may be used. A certain technique might be
required for an unusual situation or a problem patient. In the final analysis,
the skill of the dentist and the cooperation of the patient are probably the
most important factors in securing an accurate centric relation record.


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