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Practice: Recording The Retruded Contact Position: A Review of Clinical Techniques
Practice: Recording The Retruded Contact Position: A Review of Clinical Techniques
PRACTICE
IN BRIEF
● The retruded contact position (RCP) is a relatively reproducible maxillomandibular
relationship. VERIFIABLE
● It is used as a reference point for mounting casts on an articulator.
● Occlusion has a biological adaptability and is not constant.
CPD PAPER
● Mandibular guidance from the operator has been shown to give more consistent
RCP recordings.
● Chin point guidance, bimanual manipulation and use of an anterior jig are recommended.
The retruded contact position (RCP) is an important maxillomandibular relation in restorative dentistry. This review will
describe RCP and consider its importance and use in the restorative dental treatment of the dentate and edentulous subject.
A comparative account of the various mandibular guidance methods used to obtain a RCP record will be presented, followed
by recommendations for fixed and removable clinical prosthodontic practice.
The three-dimensional relationship of thought. 7 The early Conical8 and Spheri- premature contact in centric relation,2 cen-
the mandible to the maxilla, and the clin- cal9 theories were superseded by the tric relation contact position (CRCP), the
ician's understanding of it, is fundamen- mechanical models of the Gnathologists.10 retruded axis position (RAP), the terminal
tal in clinical dental practice. No matter These theories were largely driven by hinge position (THP) or the ligamentous
the degree of restorative dental treatment developments in articulator design. As a position. Terminology, as alluded to earlier,
provided, be it a small occlusal restora- consequence, the terminology, teaching, is very confusing as The Glossary of
tion to a full-mouth rehabilitation, the clinical methods and research in this Prosthodontic Terms11,12 has changed defi-
occlusion is affected to a greater or lesser important area has left many bewildered. nitions from edition to edition, and has
extent. Occlusion has been defined sim- The Glossary of Prosthodontic Terms has even cited definitions which appear contra-
ply by Davis and Gray1 as ‘the contacts contributed to this confusion by periodi- dictory. Moreover, there are seven different
between teeth'. These contacts can be cally altering the definitions of certain definitions for centric relation (CR) in use
considered statically or dynamically, as relations.11,12 In recent years, the engi- (Table 2). Jasinevicius et al.14 surveyed the
teeth slide over each other during neering model of occlusion has been tem- level of consensus regarding the definition
mandibular movement. In addition to the pered by an increased appreciation of the of CR in seven US dental schools. The
occlusion, the masticatory system is also biological aspects of the masticatory sys- authors found that numerous definitions
composed of the periodontal ligaments, tem.7 Biological occlusion does not dis- were used at each institution and the longer
the temporomandibular joints (TMJ), the card the important work undertaken over a clinician had been qualified for correlated
muscles of mastication and their associ- the past 150 years, but recognises the with which definition they employed. It was
ated ligaments.2 The system is under the interaction between the component parts suggested that this had an adverse effect on
control of higher centres in the central of the masticatory system and the fact undergraduate dental student's under-
nervous system. there is a degree of adaptability.7 standing of CR, even diminishing the value
The interpretation of various mandibu- This review will describe RCP and con- which they placed on CR. While the debate
lar positions is fraught with confusion3–6 sider its importance and use in restorative over the semantics of CR continues
as over the past 150 years there have been dental treatment of the dentate and eden- amongst academic dentists, many clini-
a succession of occlusal schools of tulous subject. A comparative account of cians still consider centric occlusion (CO) as
the various mandibular guidance methods a synonym for the intercuspal postion (ICP,
1*Specialist Registrar in Restorative Dentistry, used to obtain an RCP record will be pre- Table 1). This is obviously incorrect if the
2Lecturer/Honorary Specialist Registrar in Restorative sented, followed with recommendations for Glossary of Prosthodontic Terms is to fol-
Dentistry, Guy's & St Thomas' Hospital NHS Trust, Unit of fixed and removable clinical prosthodontic lowed, but until terminology and teaching
Restorative Dentistry, Floor 26, Guy's Hospital, London practice. issues are resolved and consensus is
Bridge, London SE1 9RT
*Correspondence to: Paul Wilson reached, this concept will probably persist.
Email: paul.wilson@gstt.sthames.nhs.uk THE RETRUDED CONTACT POSITION OF We do not wish to contribute to the confu-
THE MANDIBLE sion, and to this end we will follow the defi-
Refereed Paper
doi:10.1038/sj.bdj.4811130 Terminology nitions reproduced in Table 1 and the most
Received 09.01.03; Accepted 14.05.03 The retruded contact position (RCP; Table1 recent definition of CR in Table 2 (Defini-
© British Dental Journal 2004; 196: 395–402 and Fig. 1) is also variously known as the tion No. 1).
PRACTICE
PRACTICE
PRACTICE
can be found accurately using a kinematic are operator-guided. Kaplan35 has warned There is no way of verifying the nature of
facebow. The latter method is time-con- against the use of excessive forces during any unwanted tooth contact or the retrusion
suming and it has been suggested that no mandibular guidance. Forceful mandibular of the mandible. In addition the wax may not
practical advantage is gained.26 retrusion by the operator can place the be uniformly softened which can lead to
Other influences that affect the RCP condylar heads too inferiorly, as they move inaccuracies in the recording.34,41,42 This
recording may be difficult for the clini- down the posterior slope of the glenoid fossa technique can also be used, with wax rims,
cian to control. These include general and rotate about the temporomandibular for the edentulous patient.
health, attitude to treatment, co-opera- ligaments.36 Furthermore, this can cause
tion and comprehension of the proce- patient discomfort which results in resist- Physiological technique43
dure, the patient's body, head and tongue ance to the applied load. Some force applied This method uses cones of soft wax placed
position, state of relaxation, medication by the patient, from the muscles of mastica- posteriorly. The patient swallows several
and state of anaesthesia. Only a few of tion, is beneficial when locating the condy- times, simultaneously the mandible retrudes
these have been assessed objectively. lar heads in an antero-superior position in and the recording is made. Besides the uni-
Helkimo22 found no difference in record- the glenoid fossae.37 However, too much formity of softness of the wax, there is no
ings between supine and upright force is detrimental as the mandible flex- control over the mandibular retrusion nor
patients. Pain from the operator's guid- es38,39 about the horizontal plane. any tooth contact. This technique is more
ance technique, the temporomandibular appropriate for the edentulous patient.
joints or from muscle tension will result Patient-guided recording of RCP
in reflex mandibular protrusion and Schuyler technique40 (Fig. 3)
hence erroneous recordings. Psychologi- This quick and simple technique involves the
cal tension and anxiety will also increase patient placing the tip of the tongue to the
muscle tension. The number of teeth, back of the palate and closing into a horse-
their condition or the ridge form of eden- shoe of softened wax with light pressure.
tulous patients will effect the stability of
the recording medium and thus the qual-
ity of the recording.
PRACTICE
PRACTICE
ing and permits minimal tooth separation so period of time, usually between 10–20
that the recording medium is as thin as pos- minutes prior to registration, in order for
sible. The Lucia jig is made from self-curing proprioceptive input to be lost. No adjust-
acrylic resin (ie DuraLay II, Reliance ment using gothic arch principles is possi-
Dental MFG Co., USA) on a study cast or in ble and once the correct anterior spatula
the mouth. If carried out intra-orally care guidance is achieved, registration materi-
must be taken because of the exothermic al is used to record the relative position of
setting reaction of the acrylic. At the dough the mandibular and maxillary teeth.
stage, the acrylic resin is adapted to the
upper anterior teeth, using soft paraffin as a
separator. The palatal acrylic is manipulated
to just cover the palatal soft tissues. The lin-
gual aspect should slope posteriorly and
superiorly at an angle of between 40–60°
and a wooden spatula can be useful in
achieving this. While the jig sets it must be
gently taken on and off the teeth to avoid Fig. 11a A book of multi-coloured leaves which
engaging undercuts and to reduce the can be selectively used as a leaf gauge (Panadent
chance of thermal trauma. Once completed Corp., CA, USA)
the jig is adjusted using articulating paper
placed on the palatal aspect whilst the
patient performs lateral and antero-posteri-
or excursive movements. A selected lower
incisor scribes an arrow-head pattern, the
Fig. 10 An anterior clinical view
‘wings' and ‘tail' of which can be ground showing the use of tongue blades to
away to leave the apex. This process is produce an anterior reference point
repeated until a raised area of acrylic at the during an RCP registration. Enough
apex remains. This is the location of the wooden blades are used to just achieve
retruded position and the vertical height is posterior disclusion of the teeth
then adjusted until the posterior teeth are
just out of contact. The record is made at this Anterior guidance by a Leaf Gauge55
position with the jig in the mouth. It is (Figs 11a, 11b, 11c)
important to note that while the jig is being Another variation of the Lucia jig principle
adjusted out of the mouth, the patient must involves the leaf gauge. Originally, a book of
bite on a cotton wool roll or a saliva ejector ten acetate leaves was described but now dis- Fig. 11b A specific thickness of leaves has been
in order to keep the teeth discluded other- posable paper versions are also available selected in order to achieve an anterior
wise the training effect of the jig will be lost. (Panadent Corp., CA, USA). The leaves pro- reference point for registration of RCP
This method can also be used if upper ante- vide the anterior reference point and the
rior teeth are missing. The jig is simply made degree of tooth separation can be altered until
to span the edentulous area and is adjusted the teeth achieve disclusion. No adjustment
in the same manner. using gothic arch principles is possible. A reg-
istration support wafer permits the registra-
Anterior guidance by a tongue blade54 tion of the inter-dental record (Fig. 11c).
(Fig. 10)
The tongue blade method uses wooden Anterior guidance by a OSU Woelfel
spatulas instead of a custom made Lucia Gauge56 (Figs 12a,12b)
jig to provide an anterior reference point. This method was developed by Woelfel at
The degree of tooth separation can be Ohio State University (OSU) and aims to
altered by the number of spatulas used. simplify the Lucia jig technique while still Fig. 11c A support wafer can then be added to
support the registration medium
The patient's teeth must be discluded for a achieving an anterior point contact at the
PRACTICE
retruded position. The specially designed opposite sides of the same patient.66 The
device (Girrbach Dental GmbH, Germany) consistency of the Lucia jig combined
has a graduated acetate bite platform, the with chin-point guidance or bilateral
position of which is adjusted antero-poste- manipulation has been confirmed in
riorly until the teeth are minimally out of other studies.34,67 In McKee's study59 the
contact. A registration support wafer can effect of training on mandibular guid-
then be added and the inter-dental record ance was evaluated. Prior to instruction,
made (Fig. 12b). bimanual manipulation, chin point guid-
ance and the Lucia jig produced similar
Power-centric registration method57 results, with a spread of recorded posi-
This technique departs from the guided tions made. After training in bilateral
methods described so far in that the opera- manipulation only, more consistent
tor employs a directed force to achieve a results (tolerance of 0.11 mm) were
retruded mandibular position. With the Fig. 12a An anterior clinical view showing the
achieved with it than with chin point
dentist standing in front and to the right of graduated acetate OSU Woelfel gauge (Girrbach guidance and a Lucia jig. The influence
the supine patient, the left thumb and fore- Dental GmbH, Germany) of patient-applied muscle force during
finger are placed over the upper teeth. The the RCP recording must also be consid-
right thumb is placed on the superior ered. Omar and Wise38 found mean flex-
aspect of the chin, while the second and ure of the mandible, in the horizontal
third fingers take up position along the plane, to be 0.073 mm when patients
inferior border of the mandible. The opera- apply maximal occlusal force.
tor's right arm is stiffened and pressure is
applied from the shoulder by leaning. It has Anecdotal evidence
been suggested that reflex muscle shorten- Wise25 described RCP location tech-
ing acts to retrude the mandible but it is niques for the dentate patient based upon
likely that the mandible is pushed too far the relative ease of mandibular manipu-
posteriorly, thus producing an error in RCP lation. He classified patients as ‘easy',
registration. ‘manipulation with slight difficulty' and
‘manipulation with more difficulty'. This
COMPARISON OF RCP GUIDANCE classification is anecdotal and would
Fig. 12b A registration support wafer can be used
METHODS with the OSU Woelfel gauge certainly vary between clinicians, but
Clinical variation in RCP recording might serve as a guide for RCP guidance
It is important that the interocclusal technique selection, encouraging the
record is made at the correct OVD using Mandibular guidance studies dentist to examine mandibular move-
an accurate, dimensionally stable medi- The duplicability of gothic arch tracings ment more carefully. Wise suggested
um and an appropriate, well practised has been studied in dentate subjects and bimanual manipulation for easy patients.
mandibular guidance technique.33 These found to be subject to diurnal varia- Anterior guidance from a tongue blade
principles should help the clinician make tion.13,61,62 The same apex position could followed by bimanual manipulation was
a retruded mandibular record which is not be reproduced in any of the subjects recommended for slightly more difficult
accurate and reproducible. Helkimo22 and the greatest changes in position were patients. Very difficult patients required
suggested the range of clinical variation in a mediolateral direction. This said, construction of a Lucia jig which may
to be 0.07—0.11 mm antero-posteriorly, Helkimo22 reported that guided need to be left in situ for up to 30 min-
while Watson et al.58 found inter-clini- mandibular closure gave more repro- utes in order to disrupt proprioception.
cian variation was much greater than ducible RCP recordings than no guid- For some very difficult patients, proprio-
intra-clinician variation when recording ance, in both anteroposterior and medio- ceptive deprogramming may need to be
CR in edentulous patients. McKee59 lateral directions. Similar results were accomplished using an occlusal splint for
echoed these findings and called for found by Kabcenell,16 who used bilateral an extended period.23,24,61
more undergraduate and postgraduate manipulation, moderate and heavy pres-
training in this important skill. Eriksson sure chin point guidance and the SUMMARY
et al.30 has investigated the clinical fac- Schuyler technique.40 Moderate chin RCP, that three-dimensional maxillo-
tors influencing the reproducibility of point guidance yielded the most consis- man-dibular relationship which results
interocclusal recording methods in fixed, tent results. Kantor et al.64 investigated from initial teeth/tooth contact as the
partial and complete prosthodontic the influences of swallowing, chin-point mandible hinges about the terminal
cases. It was found that the dominant guidance, Lucia jig, bilateral manipula- hinge axis, is a relatively reproducible
influence upon reproducibility was clini- tion and the myo-monitor on the repro- position. As a reproducible position, it is
cal technique rather than recording ducibility of RCP recording. The most useful in the restorative management of
medium or the particular mandibular consistent guidance methods were the dentate and edentulous individuals and
position recorded. Conversely, Utz et Lucia jig and bilateral manipulation, as a reference point for the registration of
al.60 has suggested that reproducibility is which have been demonstrated by elec- transfer records, so that casts can be
unachievable, regardless of technique or tromyographic studies to produce the mounted on articulators. Although
technical excellence. Utz et al.60 may be least temporalis and masseter activity.65 patients are reorganised into this position,
right in that absolute reproducibility of The myo-monitor and swallowing tech- it has been shown that a slide between
RCP is impossible, however differences niques were extremely variable. Record- RCP and ICP will be reintroduced after
of 0.08 mm have lead Posselt15 to con- ings made using the myo-monitor have 2–12 years.28 This confirms that the occlu-
clude that these variations are 'probably been shown to be anterior to RCP, vari- sion is not constant but exhibits biological
clinically insignificant'. able between patients and variable on adaptability. Adaptability also means that
PRACTICE
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