Cl<1JTKIC

IOSITION

Dcpavtmelzt

of Prosthetics,

iVrrrthsarstcrn

Unioersity

Dental

School,

Chicago,

111.

have been accepted stands out as the vaguest and most ambiguous, although certainly one of the most important. Most definitions are based on clinical observations with consequent interpretations of the actual situations. If one is to define centric relation, it must be done anatomically since it is basically an anatomic study. A definition of this relation which embodies the anatomy of the area was suggested by Thompson,l who discussed the three mandibular positions, viz., the rest position, the occlusal position, and the centric position. He is of the opinion that the centric position cannot be described in a few words, but that it is a concept that must be understood in order to be applied clinically. He says : The centric position cannot be formulated in a definition with a few words: but rather it is a concept that must be understood. Centric position is not only the mandibulo-maxillary relation where the teeth should occlude in the normal or good functioning situation, but also where the condyle of the mandible is in a balanced and unstrained position in the mandibular fossa. This position exists when the antero-superior surface of the condyle is in close approximation with the postero-inferior surface of the articular eminence. This relationship does not vary much in individuals under normal circumstances, but the space posterior and superior to the condyle does var; in size. If the path of closure from rest to the occlusal position is normal through an acceptable interocclusal clearance, the occlusal position will be identical with the centric position. If the path is abnormal because of tooth interference, or if the interocclusal clearance (free-way space) is too small or absent or, on the other hand, too large, the occlusal position will not be identical to the centric position, and an abnormal functional situation will exist. This definition differs from the usual type of definition of this relationship in that it does not show how to establish a centric position, except that it can be more likely establishecl if it is understood on an anatomical rather than an empirical basis. It also does not insist, as so many of the definitions do, upon ~etrz~~io~. I would like here to emphasizethe fact that a mandible---anatomically speaking -can be retruded beyond what we should consider centric into a strained retruded position. This has always been generally accepted. There is a space distal to the condyle which contains soft tissue and the nutrient supply to the temporomandibular joint, when the mandible is in its normal rest position and occlusal position. This area can be encroached upon hy a forced retrusion. We have here introduced another important factor which is physiology. Since the mandible can he retruded anatomically by conscious effort, or if it has been occluding in a position
Received for publication April 2. 1051.
384

the many concepts in denture construction which A MONG by the profession, the concept of the centric position

Volume Number

1 4

CENTRIC

POSITION

385

of posterior mandibular displacement because of occlusal interference, what happens If patients are obwhen a denture is constructed to these posterior positions? served with this possibility in mind, the practitioner will find the existence of abnormal functional situations similar to the following. In the first type, the patient had been wearing a partial lower denture which to the occluded with natural upper teeth. The denture had been constructed popular concept of the centric relation which emphasized retrusion and forced, therefore, a retruded relation whenever the teeth were brought into occlusion. The patient presented with symptoms of clicking in the joint, tiredness around the jaws and face, and inability to use the appliance. Cephalometric radiographic examination showed no obvious deformation of the condyles, and made certain that the occlusal vertical dimension was adequate but not excessive. It did reveal an abnormal posterior-superior path of closure from rest to the occlusal position. Believing that a retruded relation existed, the patient was asked to move the mandible slightly forward from this position so that the occlusal position was identical with the centric position, and after covering the occlusal surfaces of the partial denture with a self-curing acrylic the patient held this new relation until it was registered permanently on the appliance (three minutes). I3y studying the patient over a period of weeks, and by judicious spot grinding, the acquired improper closing pattern which caused a retrusion of the mandible, and an encroachment upon the soft tissue was broken, and the symptomology began to disappear. A new partial lower denture was constructed. The upper cast was mounted by a face-bow on a Hanau articulator, and the lower cast was mounted to the relation established in the old appliance. Teeth were set to this position, and ground in to eliminate gross interference. At the try-in of the metal framework with the teeth set in wax, adjustments were made to provide for comfort and balance. The denture was subsequently completed. The patient, after a few adjustments to relieve points of interference, was asymptomatic and able to use the appliance. It is interesting to note that three months later it was still possible for the patient to close into the retruded position, but at this time it felt uncomfortable and abnormal, and a normal anterior-superior path of closure from rest to occlusal position had been restored. The second type of abnormal functional situation concerned a cotnplete upper and lower denture. The patient had been edentulous for twelve years, and had been wearing dentures throughout that period. The dentures with which she presented were constructed three years previously, but could not be used efficiently. Here, again, the patient presented with a clicking in the temporomandibular joint, pain, and an inability to wear or use the lower denture. Cephalometric radiographic examinations were made to determine the adequacy of the occlusal vertical dimension and lack of condylar deformation, and an abnormal posterior-superior path of closure from rest to the occlusal position was noted. An autopolymer was placed over the lower teeth, and the jaw was manipulated forward, with the help of the In this case the patient, into what was believed to be the correct occlusal relation.

386

ROBINSON

symptoms were slightly lessened. It was decided to construct a denture to this occlusal position with the thought that it would be identical to the centric position. The dentures were constructed in the usual way. The relation of the mandible to the maxilla that was obtained approximated the relation which was built into the old dentures by the addition of the autopolymer. Teeth were set up to tllis relation and, because of the fact that the patient appeared to have been in a retruded position, deep cusp teeth were used to help guide the mandible into its proper r&ltion. The cephalometer was used to check each step along the way, and the tqqxr The final centric relation was determined at this point. denture was processed. The occlusion on the lower denture was modified to accept this relation, and the lower denture was processed. Occlusal adjustment of the completed dentures was done in the usual matsner, and the dentures were inserted. The tiredness, clicking, and inability to use the dentures disappeared almost immediately. Four months later, the patient could be forced into a retruded relation, but it was becoming more strained and uncomfortable in this position. A normal anterior-superior path of closure from rest to occlusal position had been restored. This was a change iron1 the abnormal posterior-superior path of closure that existed when the occlusal position of the jaw was posterior to the centric position.
CONCLUSION

Anatomically, it is possible for the mandible to be in a strained retruded position, and in a position of posterior displacement when the teeth are occludecl. Physiologically and functionally this position leads to a classic symptomology, namely : crepitus, pain, and tiredness of the jaws. By careful manipulation of the mandible, a new centric position which is closer to the normal physiologic relaBy watching and adjusting this position, an acceptable tionship can .be established. centric relation can be established.
REFERENCES

1. Thompson, John R. : Oral and Environmental Factors as Etiological sion of the Teeth, Am. J. Orthodontics 35:33-53, 1949. 2. Thompson, John R. : Unpublished manuscripts.
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Factors in Malocclu-