Journal of Oral Rehabilitation 2000 27; 1013–1023
Review
An appraisal of the literature on centric relation. Part II
A. KESHVAD & R. B. WINSTANLEY Department of Restorative Dentistry, School of Clinical Dentistry, University of
Sheffield, Sheffield, U.K.
SUMMARY The literature directly and indirectly re-
lated to centric relation (CR) has been reviewed
chronologically. More than 300 papers and quoted
sections of books have been divided into three sec-
tions. The first two parts of the paper are related to
CR. Studies in this group mainly compared either
the position of the mandibular condyle or the
mandible itself in different CR recordings. Various
tools were discussed for this purpose. The third
Part II: centric relation 1981 –
Continuing this review of the literature on centric
relation (CR), Carwell & McFall (1981) investigated
variations in occlusal prematurities and condylar posi-
tions using different methods for determining CR.
Techniques employed included bilateral manipulation,
the chin point method and an anterior guidance jig.
Transcranial temporomandibular joint (TMJ) radio-
graphs were used in one-third of the subjects to further
analyse condylar position. The results showed the pres-
ence of additional CR contacts with the bilateral ma-
nipulation technique, which indicated more finite
information during occlusal analysis. No measurable or
tracing differences of condyle position in TMJ radio-
graphs were observed using the two methods.
Teo & Wise (1981) reported the position of the
horizontal axis of rotation of the condyles when
retruded axis position (a new term suggested by them)
registrations were taken on seven subjects using an
anterior jig with chin point guidance, an anterior jig
with chin point guidance and applied muscle force by
the subject and, finally, an anterior jig with bilateral
manipulation. The results suggested that the most su-
© 2000 Blackwell Science Ltd
part deals with CR– centric occlusion (CO) dis-
crepancy. CR remains one of the controversial issues
in prosthodontics and orthodontics. Debates relat-
ing to mounting casts on the articulator by repro-
ducible records for orthodontic treatment planning
and end results, and whether or not orthodontic
treatment based on CO causes temporomandibular
joint (TMJ) dysfunction, remain unsolved. The ref-
erences are listed at the end of Part III.
perior positions were obtained with the anterior jig and
applied muscle force, which was also the most incon-
sistent method. The most consistent method was the
anterior jig with chin point guidance. A custom-made
Buhnergraph constructed on a Whip-Mix articulator
was used to compare the centric records.
In another study, Omar & Wise (1981) investigated
the possibility of mandibular flexure affecting centric
records. The measurements involved flexure in the
horizontal plane when CR recordings were made with
an anterior jig, chin point guidance and patient muscle
force. The authors hypothesized that an arch width
change occurs at the tooth level, as a result of strong
bite force, which causes a flexure of the mandible.
Assessment of 10 subjects with intact dentitions indi-
cated 0.078 90.028 mm flexure. They suggested that
articulators may require modification to allow for
mandibular resilience and that use of a closed mouth
impression technique and a non-muscle CR registra-
tion technique is mandatory.
The power centric registration, using a two-piece
wax bite, is a technique advocated by Roth (1981). The
method incorporates mandibular manipulation and an
anterior stop to register the most superior and anterior
1013
1014 A. KESHVAD & R. B. WINSTANLEY
position of the condyles. The anterior stop is fabricated
in wax using downward chin point guidance with
upward pressure at Gonion to position the condyles
both superiorly and anteriorly. The hardened anterior
stop, once verified, is then used along with a softened
posterior piece of wax to seat the condyles in the most
superior position using the patient’s own musculature.
Tradowsky & Kubicek (1981) described biophysical
aspects of mandibular position in an interesting paper.
They showed that the Gothic arch central bearing
screw could be placed on a line connecting the tips of
the right and left maxillary first premolars to avoid
leverage flexure of the mandible during tracing. This
point was referred to as the physiologic equilibrium point
of the mandible. According to the authors, the
‘… physiologic equilibrium point of the mandible is defined
as the point where the resultant force of the vectors of all
closing muscles of the jaw during maximal contraction inter-
sect the occlusal plane, with all other mandibular muscles
resting’. Placement of the stylus anteriorly or posteri-
orly to this point of equilibrium could cause errors in
centric registration.
An interesting radiographic study by McWilliam, Is-
berg-Holm & Hellsing (1982) was conducted at the
Karolinska Institute, Sweden. This pilot study investi-
gated the possibility of using subtraction radiography to
promote images obtained using either one-handed
push back or bimanual manipulation techniques. The
authors indicated that this kind of radiography offers
precise detection of small differences in condylar posi-
tion. They concluded that, as a result of intra-individ-
ual variations between sides, bilateral manipulation
should be undertaken in studies of this kind. A second
study (Hellsing, Isberg-Holm & McWilliam, 1983) was
carried out to compare the same methods with a larger
sample size. The authors showed that both methods of
recording CR resulted in condylar positions that did not
differ significantly from each other. From a radiation
hazard point of view, neither the repeatability nor the
source of error were examined in their study.
Electromyographic (EMG) studies of head and neck
muscles revealed evidence of muscle activity in differ-
ent mandibular positions. Buxbaum et al. (1982) and
Duthie & Yemm (1982) showed that, with the head
erect, active CR positioning induces activity in both
temporal muscles and in the supra-hyoid and infra-hy-
oid muscles, with little contribution from the masseter
and lateral pterygoids. It was also shown that the
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013–1023
anterior temporal fibres act as a stabilizer, while the
middle and posterior fibres retrude the mandible in
co-operation with the supra-hyoid muscles. The infra-
hyoid muscles stabilize the hyoid bone and the lateral
pterygoid muscle stabilizes the disc of the TMJ. How-
ever, Funakashi & Amano (1973) believed that head
posture affected the postural and intra-border position
of the mandible, and not the border positions such as
CR.
Muraoka & Iwata (1982) compared one-handed and
bimanual methods. They constructed an aluminium
positioner that was affixed to the patient’s chin, to
exert pressure upward and backward. They called this
the Muraoka Centric Locator (MCL) technique. Two
one-handed techniques (three finger and thumb finger
push back) and two bimanual techniques (bimanual
mandibular manipulation (BMM) and MCL) were
compared. It was found that three methods of manipu-
lation (three finger, bilateral and MCL techniques)
were equally effective in obtaining the uppermost posi-
tion of the condyles in CR. The thumb push back or
conventional chin point guidance positioned the
mandible too far posteriorly to be considered as CR.
Centric occlusion (CO) was found to be always anterior
to CR. No medio-lateral analysis was performed in this
study.
An interesting study by Adel & Abdel-Hakim (1982)
was performed to eliminate the effect of bite raising in
recording CR using the Gothic arch tracing and to
observe CR consistency. Patients requiring extraction
of teeth were selected and Gothic arch tracing clutches
were made, reducing the height of the existing teeth to
bring the facial height to the vertical dimension of
occlusion. Then, the swallowing position was marked
intra-orally at the original vertical dimension of occlu-
sion; it was found that the swallowing technique was
not consistent. The design of the study is suitable for
comparing some other valid CR recording techniques.
However, Adel and Abdel-Hakim’s (1982) conclusion
is debatable in that they said that just because the
swallowing method was not coincident with the inter-
cuspal position it was not acceptable. Today, we know
that nearly 90% of the population have a different CR
and CO and that only those with complete dentures or
full mouth reconstruction have coincident CR and CO,
both being created by the dentist.
Prior to the publication of the Glossary of
Prosthodontic Terms (1987), very few practitioners ar-
 A N A P P R A I S A L O F T H E L I TE R A T U R E O N C E N T R I C R E L A T I O N
gued the need for a new definition. Gilboe (1983a) was
one who did. He insisted on ‘the most anterior superior’
position and argued that CR was an anatomical and
functional reference position in the equilibrium loca-
tion of the condyle on the slope of the eminence. He
stated that the morphological and functional analyses
of the TMJ and associated structures demonstrate that
stresses are directed supero-anteriorly. In a separate
paper (Gilboe 1983b), he defined CR as the most supe-
rior position of the mandibular condyles, with the
central bearing area of the disc in contact with the
articular surface of the condyle and the articular emi-
nence. However, he added that all manipulative tech-
niques of CR either presuppose or ignore two critical
specifications: disc location and the resistance of the
capsular ligament to posterior displacement. He re-
jected the use of radiographs and tomograms for estab-
lishing the condylar position. He also questioned
posterior location of the condyles in CR by stating that
‘The mere reproducibility of a position can not be construed
as being either desirable or functional’. He evaluated the
different methods of recording centric, including BMM,
and identified the position of the disc by fluoroscopic
examination combined with arthroscopy. Even slightly
displaced discs could be centred by correct bilateral
manipulation and he stated that Dawson’s bilateral
manipulation positions the mandible posteriorly while
simultaneously directing force supero-anteriorly on the
condyles. He related this to the position of the disc
itself, showing that pressure exerted through the
condylar articular surface on the slightly displaced pos-
terior band tends to wedge the disc in its correct posi-
tion— the central bearing area. He also showed, by the
same method, that distally directed chin point guidance
has a tendency to force the condyle off the disc.
In 1984, Celenza wrote two papers. The first was
mostly about CO (Celenza, 1984a), while the second
was dealt with CR (Celenza, 1984b). In the first paper,
he discussed CO, occlusal adjustment and the confor-
mity philosophy of occlusion. He quoted the 1977
edition of the Glossary of Prosthodontic Terms as the
standard definition of CO. He stressed the role of the
neuromuscular system in directing the mandible to CO
by stating ‘Prior to tooth contact, the neuromuscular mecha-
nisms, along with monitoring sensory activities of capsular
ligament receptors, guide the mandible toward the centric
occlusion position. The approach angle is influenced by prior
feedback information (which is not completely understood)
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013– 1023
1015
and by the postural position of the patient. Reclining position
(extension) results in a more posterior pathway. Inclining
position ( flexion) results in a more anterior pathway’. The
difference between intercuspal position (ICP) and max-
imum intercuspation (MI) was explained in his paper.
The 3–5 ms difference between the two was explained
as the time when the teeth come into first contact and
full contact. He stated that because CO is an ever-
changing position and CR is said to be always related
by the same distance to CO, then CR is also not a
constant position.
In his second paper, he objected strongly to the
definition of CR in the Glossary, stating that ‘The defin-
ition of centric relation requires the condyles to be in their
most posterior position in the glenoid fossa. The inclusion of
the phrase ‘‘from which lateral movements can be made’’
implies that there are posterior positions where no lateral
motion can be made. Every investigation of mandibular
motion has shown the contrary’. He also stated that be-
cause the only area of the joint to be covered with
articular cartilage is the posterior slope of the eminence
and the anterior portion of the condyle, the phrase
most posterior is incorrect. He stated that posterior place-
ment could actually disarticulate the joint and that the
anterior superior placement appears to be the most
logical direction.
In his 1984b paper, Celenza used the anatomy of the
TMJ to explain why CR in the joint is an anterior-pos-
terior area, and not a point. In this area, the choice of
the condyle, he stated, was anterior-superior, poste-
rior-superior and central-superior. He also criticized
the idea of apex of force position as a point of CR in the
TMJ. To declare why the midmost position of Wein-
berg is also incorrect, he used the following logic: ‘The
most superior portion of the joint cavity is the glenoid fossa.
The glenoid fossa has no articular cartilage. This portion of
the joint also contains the posterior band of the articular disk.
This band is the thickest portion of the disk. It contains blood
vessels and nerves and is not reinforced with cartilaginous
cells’. He believed that, because in the biological system
of the joint the fossa and the rami are not symmetrical,
the idea of concentricity in RUM (rearmost, upper-
most, midmost) centric registration is not always cor-
rect. He stated that ‘symmetry and equality are not the
order of biological structures; adaptation is’. He described
three CR registration methods—chin point guidance
(CPJ), BMM and three finger CPG—as suitable meth-
ods of locating CR. He added that BMM is appropriate
1016 A. KESHVAD & R. B. WINSTANLEY
with joints that have lost support and CPJ can easily
deflect the mandible on one side because it is one-
handed.
Balthazar et al. (1984) compared three mandibular
positions: myo-centric (MC) position, CO and CR (us-
ing the chin point technique, CPJ, of recording). He
considered MC and CPJ as hinge axis records. Re-
peatability of the records was compared using a Buh-
nergraph and the results suggested that the MC
registration produced a mandibular position in the
horizontal plane that was both non-repeatable and
inconsistent with CO and CR registrations. It was also
found that CPJ was repeatable if the bite opening was
limited (the thin CR record). Balthazar also indicated
that MC has equal bilateral influence on the mandibu-
lar elevator muscles, but its effect on the deeper pro-
truding muscles was inconsistent, implying that MC
did not exert a uniform effect on the muscles of protru-
sion. The paper was criticized in a letter from Jankel-
son (1985), who stated that the hinge axis was
irrelevant to the CR position and that the myo-monitor
was not designed to register the hinge axis. Jankelson
also stated that the sole objective of registering the MC
position of occlusion is to determine the three-dimen-
sional position in space where the mandible is ortho-
paedically orientated in relation to the skull to ensure a
relaxed neuromuscular environment for a finished
case.
The effect of splint therapy on the alteration of CR
was investigated by Serrano, Nichols & Yuodelis (1984)
using chin point guidance. A stabilization splint was
made and XR was compared before and after splint
therapy. It was shown that the repeatability of the CR
record was not affected by this treatment, but that a
superior anterior position of the condyles was induced.
Capp & Clayton (1985) believed that the ability to
record a stable and reproducible relationship of the
mandible to the maxilla was dependant on the dentist,
the patient, the registration method, material and the
time of recording. They compared the initial tooth
contact of two CR methods on articulated casts in a
subject without TMJ dysfunction (TMD). They showed
that BMM produces a more anterior position than the
chin point guidance and anterior jig method. However,
the results of the study are not reliable because data
from only one subject were used.
The contact of teeth at CR is another point of discus-
sion. Mohamed & Christensen (1985) believed that a
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013–1023
position of CR is not defined by a specific contact
relationship between maxillary and mandibular teeth.
The following paragraph is their approach to CR:
‘It (CR) is mandibular border position to centric occlusion
and without occlusal tooth contact. It is mainly based on
spatial relationship between the components of the temporo-
mandibular joint e.g. the osseous component of the condyles,
articular fossa, and tubercles. It is a passive border position
where each slightly rotated condyle, with each interposed
articular disk is braced against the superior part of each
articular fossa and the supero-posterior aspect of each articu-
lar tubercle.’
Hobo & Iwata (1985) developed a new electronic
mandibular recording system. Different techniques of
condylar positioning, chin point guidance (CPJ), BMM
and unguided closure were tested. Displacement of the
condyles was monitored three-dimensionally. The
measurements were performed directly on the subjects
to limit the technical errors produced in conventional
methods when pouring casts and transferring them to
articulators. They concluded that BMM showed the
most consistent repeatability, CPJ placed the condyles
posteriorly and inferiorly, and unguided closure re-
vealed lateral displacement of the condyles in CR.
Dawson (1985) defined CR as the relationship of the
mandible to the maxilla when the properly aligned
disc–condyle assemblies were in the most superior
position against the eminentia, irrespective of tooth
position or vertical dimension. He emphasized the
condyle disc alignment, and considered this factor as
the first requirement in recording CR. Another re-
quirement, he stated, was that the condyles should be
against the eminentia. When all of these requirements
were met, then the condyles would assume a position
that Dawson called ‘the apex of force position’.
CR studies conducted in the mid-1980s are very
much related to the TMJ and put more stress on the
condyle–disc eminence complex as opposed to earlier
studies, which were more concerned with CR–CO dis-
crepancies and tooth positions. Mohamed & Chris-
tensen (1985) reviewed the literature on CO, CR, CR
occlusion and the position of rest, and analysed all of
the factors affecting these mandibular positions in de-
tail. Weinberg (1985), who very much relied on radio-
graphs of the TMJ for treatment of TMD and the
correct placement of the condyles in CR, classified
condylar displacement according to his method of
treatment. He described how anterior, superior, bilat-
 A N A P P R A I S A L O F T H E L I TE R A T U R E O N C E N T R I C R E L A T I O N
eral, unilateral and posterior condylar displacement
can be detected and treated using transcranial TMJ
radiographs. His philosophy was based on the observa-
tion of joint spaces in conventional radiography. The
following paragraph is a summary of Weinberg’s
philosophy:
‘When there is no deflective slide and centric relation and
centric occlusion are the same, the clinical centric relation is
classified as functional when the joint spaces are symmetri-
cal and both condyles are concentrically positioned in the
superior portion of the glenoid fossa. If one or both condyles
are retruded or protruded, the clinical centric relation is
dysfunctional. If there is a deflective slide to the acquired
centric occlusion, the clinical centric relation can be classified
as functional if the condylar displacement in the TMJ radio-
graphs correlates with the direction and magnitude of
mandibular deflection. The correction of the deflective contacts
must result in bilateral condylar concentricity. When the
condylar position in the TMJ radiographs does not correlate
with the mandibular deflection, the clinical centric relation is
dysfunctional’.
The 1986 literature referred to the leaf gauge
method of CR recording, which in recent times has
re-appeared. In February 1985, the Committee on Sci-
entific Investigation of the American Academy of
Restorative Dentistry (Phillips et al., 1986) commented:
‘The leaf gauge seems to have gained renewed popularity as
a diagnostic aid, occlusal adjustment aid and has been shown
to be helpful in securing centric relation interocclusal
registration’.
Soon after this, Woelfel & de Jesus Nunes (1986)
published a paper about a new technique* and acces-
sory instrument for recording CR. This new system
used a thin (0·15– 0·32 mm) anatomically shaped, par-
tially perforated paper card laminated on both sides
with 0·005 in. Mylar.
In 1986, the philosophy of ‘the more posterior the
better’ was still valid, and researchers introduced meth-
ods or devices to force the mandible as far back as
possible. Based on this theory, Jankelson & Adib
(1986) designed an apparatus that enabled the opera-
tor to manipulate the mandible posteriorly while mea-
suring the retruded applied force simultaneously. They
studied the amount of applied force on the chin for
achieving CR quantitatively, and stated that because of
* OSU Woelfel leaf wafer filed with the United States Patent and
Trademark office, June 10, 1985 and assigned serial number
742,760.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013– 1023
1017
the many variables inherent in current registration
techniques, precise quantitative data were needed to
assess the reality of repetitiveness. One of the questions
posed was whether, and to what degree, variations in
the amount of manipulated force affect the repetitive-
ness of CR. Procedures for accomplishment of CR regis-
tration are described in qualitative, vague empirical
terms such as jiggling the mandible, light centric closure
and firmly seating the condyles. However, Jankelson’s
gnathoretrusive apparatus was constructed mainly to
retrude the mandible.
Jankelson declared that the specific question, i.e.
how much force is applied to retrude the mandible, is
not quantitatively answered by such a method. The
gnathoretrusive positioner indicated the amount of
force during retrusive pressure on the chin. The condy-
lar positions achieved by different forces to the chin
were measured by a kinesiograph (Jankelson et al.,
1975). The data from this study indicated that the most
posterior position was achieved using 15 lb. in male
subjects. They concluded that the use of a manually
directed CR record was unreliable and, in the light of
uncontrolled variability, not reproducible. This conclu-
sion was drawn probably because the collective data
established significant positional changes occurring in
all three dimensions as the applied force was increased
beyond 5 to 10 and then 15 lb.
Baetz & Klineberg (1986) designed a study to evalu-
ate the reproducibility of the TMJ stereographic articu-
lator. One of the conclusions in this study was that the
apex of the Gothic arch tracing and the uppermost
position of the mandible could be considered the same
in healthy adult subjects without signs and symptoms
of TMD.
Goldfogel & Harvey (1986), in a descriptive study,
demonstrated the use of the Gothic arch tracing on a
partially dentate patient with no horizontal or vertical
dental stop. They were of the opinion that the Gothic
arch tracing is a relatively simple and accurate device
capable of recording the CR position while holding a
specific vertical dimension of occlusion. A Hanau† in-
tra-oral tracer was used in this study.
Rosner & Goldberg (1986) decried the construction
of a Buhnergraph and the errors that might occur in
such a device with a fixed intercondylar width. The
total sample size of 75 in their study indicated the error
†
Hanau, Teledyne Dental, 12901, Saratoga, Avenue St. 9,
Saratoga, CA 95070, U.S.A.
1018 A. KESHVAD & R. B. WINSTANLEY
of their Buhnergraph like device to be 0·1 mm. This
device, which was more like a Vericheck, was con-
structed on a Whip-Mix‡ articulator.
In another descriptive paper on CR, Carroll, Woelfel
& Huffman (1988) stated that the significance and
advantages of being able to place the mandibular
condyles into the CR position are as follows:
(i) CR is usually an easily reproducible and comfort-
able position.
(ii) When the condyles are retruded, the mandible is
capable of repeatedly making a purely rotational
movement through an incisal separation of 10–
25 mm permitting location and transfer of this
axis to an articulator.
(iii) Patients appear to function comfortably in CR
after CR occlusal equilibration, after a full mouth
rehabilitation, during occlusal splint therapy and
wearing complete dentures.
(iv) Numerous TMJ disturbances, including pathologi-
cal changes, may occur or are triggered when
malocclusion exists because of tooth movement,
dental restorations or inadequate orthodontic
treatment.
(v) Patients with painful TMJs frequently report sur-
prisingly quick relief of their pain and other
symptoms after wearing an occlusal splint, biting
on a leaf gauge for several minutes or after a
dentist has removed the tooth or teeth which
were prematurely contacting in the CR position.
In November 1988, the American Dental Association
held a special workshop in Chicago to discuss current
TMJ and oro-facial pain developments (Reidenbach,
1988). One of the conclusions from this conference
was that the ‘optimum condylar position is in question!’
Because of the popularity that the leaf gauge gained
in the 1980s, Carroll et al. (1988) reviewed the charac-
teristics, principles of fabrication and clinical applica-
tions of an anterior jig compared with those of a leaf
gauge. The utilization of either method was recom-
mended as a simple means of routinely recording CR
closure. Both methods seem to avoid adaptive
mandibular closure patterns and dentist guided jaw
closure as well as other commonly unrecognized errors
in assessing occlusal contacts.
‡
Whip-Mix corporation, 361 Farmington Ave., Louisville, KY
40217, U.S.A.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013–1023
In 1988, a controlled study, which was published in
Japan (Nokubi et al., 1988), indicated other uses of the
Gothic arch tracing in addition to CR recording. Gothic
arch tracings of 38 TMD patients before and after
treatment were compared. The results suggested that
Gothic arch tracing was very useful for examining
patients’ jaw function, and there was a close connec-
tion with the behaviour of horizontal jaw movements
and the improvement of symptoms. Furthermore, it
became evident that the degree of maximal jaw open-
ing was closely connected with the lateral and anterior
movements and the maximal lateral deviated width
during protrusion.
The 1989 literature contains one paper (Jimenez,
1989) related to CR. In this study, EMG recordings of
masticatory muscles in three jaw registration positions
were compared. The purpose of the study was to inves-
tigate whether antero-posterior changes in mandibular
position affect masticatory muscle activity. The EMG
activity of masticatory muscles during full and partial
(10%) clenching in three mandibular positions—
retruded contact position (RCP), ICP and muscular
position (MP)—was studied. EMG data were obtained
from three bilateral muscles (masseter, anterior tempo-
ral and posterior temporal). Clenching in RCP elicited
the lowest masseter muscle activity during full clench-
ing and the highest anterior temporal and posterior
temporal muscle activity during partial clenching. RCP
required more muscle activity and permitted less biting
muscle activity. It was concluded that small changes in
jaw position are not critical for the masticatory appara-
tus provided there is good intercuspation, and that
intercuspation in RCP is not the optimal position.
Ferrario et al. (1992) used a Sirognathograph§ (a
kinesiograph manufactured by Siemens) to evaluate
three mandibular positions: rest position, swallowing
position and maximum opening. EMG was used to
standardize the muscular electrical potential of the
recorded positions. The evaluations in this study, un-
like the other studies, were not for the purpose of
comparing these mandibular positions. Each position
was independently assessed and the results indicated
that males had significantly higher vertical dimension
of rest than females, while there were no gender differ-
ences in maximum opening. Most of the subjects had a
swallowing occlusal position that coincided with or was
very near to the position of maximum intercuspation.
§
Sirognathograph, Siemens AG, Bensheim, Germany.
 A N A P P R A I S A L O F T H E L I TE R A T U R E O N C E N T R I C R E L A T I O N
Long, who first published a paper on the use of
Buhnergraph in 1970, reported in a paper in 1992
(Long & Buhner, 1992) on the use of a new instrument
called the Pathfinder. Unlike a Buhnergraph, the
Pathfinder gained no popularity and was never avail-
able commercially. The instrument consisted of two
sliding upper and lower plates that were adjusted to
the upper and lower central incisors intra-orally.
Piehslinger et al. (1993), in a study on 44 subjects,
investigated the reproducibility of the condylar refer-
ence position at the point of unstrained hinge move-
ment of the mandible. The patients were divided into
two equal groups. Group one comprised subjects with-
out signs and symptoms of TMD and group two con-
sisted of symptomatic patients. Unforced chin point
guidance was used for each subject as the CR method.
The results of the study showed no significant differ-
ence between symptomatic and asymptomatic subjects.
Reproducibility in both the symptomatic and asymp-
tomatic groups was high. It was suggested that CR is a
reference position area, and not a point, because the
latter could not be maintained in a biological area. This
area was shown to be within the range of 2 mm.
Parker (1993) believed that only two methods of
positioning the jaw for interocclusal records in CR
were consistent with the new definition (Glossary of
Prosthodontic Terms, 1987) of CR: leaf gauge and ma-
nipulative techniques. Proper use of the leaf gauge, he
stated, allows the jaw muscles to position the condyles
antero-posteriorly, as prescribed by the definition, or
similarly, the dentist may manipulate the jaw, either
bimanually or one-handed, into an antero-superior
position of the condyles. He added that any manipula-
tion that retrudes the mandible fails to conform to the
new definition of CR. He also believed that CR
achieved by these techniques is physiological.
Different methods of studying condylar positions,
such as radiography, the Buhnergraph, kinesiography
and axiography, have been described so far in the
literature review. The development of magnetic reso-
nance imaging (MRI) in the 1980s led to the use of this
device in investigating condylar position. Recently,
Alexander, Moore & DuBois (1993) used MRI of the
TMJ for condyle disc assessment in CR registration.
MRI has revolutionized the understanding of diseases
of the TMJ according to Sham & Choy (1990). How-
ever, there are limited data on the appropriateness of
this diagnostic tool for the purpose of mandibular
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013– 1023
1019
condyle positioning. They stated that the major advan-
tage of MRI was the excellent definition of the internal
joint anatomy, especially the joint disc. It also provides
correct information about the shape and position of the
articular disc, which is identifiable by its biconcave
morphology and by the fact that the signal from the
disc differs from the surrounding tissue, according to
Pharoah (1993).
The accuracy in determining the disc position and
the morphology is comparable with arthrography ac-
cording to Westesson et al. (1987) and Hansson, West-
esson & Katzberg (1989). Nowadays, many centres are
using T1¶-weighted images because of the superior
anatomical detail provided by this method. Other tech-
niques of choice use proton-weighted images and
sometimes include T2**-weighted images for the detec-
tion of abnormal fluid accumulation.
Other methods of understanding the topography of
the TMJ include:
(i) conventional radiographs, i.e. transpharyngeal
view, transorbital view (or open Towne’s), open
and closed transcranial views and
pantomography;
(ii) linear and polydirectional tomography;
(iii) computerized scanning tomography (CT scan);
(iv) scintigraphy;
(v) arthrography; and
(vi) arthroscopy.
Most of these methods are either invasive or provide
blurring of the images (Pharoah, 1993). MRI is be-
lieved (Edwards, 1993) to be the best diagnostic device,
providing sharp, detailed pictures of condyle–disc posi-
tion, without invasiveness.
¶
Tesla (T) The preferred (SI) unit of magnetic flux density. One
Tesla is equal to 10,000 Gauss, the older (CGS) unit. T1 relax-
ation time is the characteristic time constant for spins to tend to
align themselves with the external magnetic field. Starting from
zero magnetization in the z direction, the z magnetization will
grow to 63% of its final maximum value in a time T1.
** T2 relaxation time is spin– spin or transverse relaxation time;
the characteristic time constant for loss of phase coherence
among spins oriented at an angle to the static magnetic field as a
result of interactions between the spins, with resulting loss of
transverse magnetization and nuclear magnetic resonance (NMR)
signal. Starting from the non-zero value of the magnetization in
the xy plane, the xy magnetization will decay so that it loses 63%
of its initial value in a time T2.
1020 A. KESHVAD & R. B. WINSTANLEY
Alexander et al. (1993) were probably the first re-
searchers to use this diagnostic tool for CR studies.
Their study focused on the existence of a distinct jaw
position and condyle– disc fossa relationship in a symp-
tom-free population using articular mountings and
MRI. An axiographic facebow was used to locate
retruded hinge axis position. The use of the term
retruded axis is questionable because this term was
being used when the scientific community had ap-
proved the anterior superior position for centric or
hinge axis position. A mandibular position indicator of
a SAM†† articulator was used to determine the reliabil-
ity of jaw positions. CR was achieved using the leaf
gauge method. The study aimed to compare CO, CR
and retruded positions. The following results were
drawn from that study:
(i) The clinical concept of treating to CR as a preven-
tive measure to improve the disc– condyle rela-
tionship was not supported. However, the authors
are orthodontists, and the definition of CR in the
study differed from an accepted one.
(ii) Condyle centricity was observed in half of the
samples and remained consistent in CR and CO.
(iii) Thirteen per cent of the samples demonstrated an
anteriorly displaced disc that was not influenced
by posterior condyle placement. It should also be
noted that what they called a displacement might
be accepted by other authorities as the normal
positioning of the condyles.
Wood (1994) studied the reproducibility of a CR
technique using a condylar position indicator (CPI)
attached to a Panadent‡‡ articulator. This apparatus is
capable of measuring the three-dimensional changes in
the position of the condylar elements of the articulator.
Wood applied the Roth CR method five times (every
5 days) and used it to remount the lower cast and
record the data five times. It was concluded that there
was no significant difference between the five CPI
readings and, therefore, the Roth bite registration
method is highly reproducible.
MRI, which was proved to be acceptable in indicat-
ing condylar position, was once again used by Seren et
al. (1994) to assess the condyle shape and fossa
anatomy in Class III patients. The study was designed
to compare condylar position in Class III and Class I
††
SAM, TaxisstraBe 41, D-80637, München, Germany.
‡‡
Panadent Corp., Grand Terrace, CA, U.S.A.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013–1023
skeletal subjects, which resulted in different condyle
and fossa morphology in these two groups of subjects.
It is interesting that some of the papers related to
prosthodontics and occlusion appear in orthodontic
journals. This is because CR is directly related to all
orthodontic treatments but is approved by few or-
thodontists. Wood et al. (1994) designed a study to
investigate the relationship between different incisal
biting forces and condylar seating. Bite force was mea-
sured with strain gauges in 22 subjects. The true point
of condylar rotation was found on the subjects’ faces
and they were asked to bite on the anterior strain
gauge while the mandible was in hinge axis point.
Condylar position was measured with no force, then
with bite forces of 4·5 kg, 7·5 kg and a comfortable
maximum. Biting force significantly affected condylar
movement. As incisal bite force increased, so too did
the amount of condylar seating to an average of
0·49 mm anteriorly and 0·27 mm superiorly using
maximum biting force. Therefore, it was concluded
that when taking a CR record, a technique involving
an anterior stop and sufficient biting force should seat
the condyles more fully. However, the authors admit-
ted that the amount of condylar seating varies between
individuals and the practice of using average amounts
of seating is not recommended. As a result of incisal
bite force, the direction of movement of the condyles
was anterior and superior. A bimanual method of
recording CR was used in the study to seat the
condyles before exerting the bite force. They stated
that when taking a CR record, a technique involving
an anterior stop and sufficient biting force should be
used to seat the condyles more fully. It seems that the
authors meant more anterior superior by using the term
‘fully’. Other studies implementing techniques to mea-
sure the amount of condylar seating have been in
agreement (Lundeen, 1974; Teo & Wise 1981; Ito et al.,
1986). It was suggested that the amount of condylar
seating varies between individuals and the practice of
using an average amount of seating is not
recommended.
Dawson (1995) wrote a purely descriptive paper
about the new terminology for CR. He stated that CR is
the accepted term for defining the condylar axis posi-
tion only of intact, completely seated, properly aligned
condyle disc assemblies. He commented that some
structurally deformed TMJs may function comfortably,
 A N A P P R A I S A L O F T H E L I TE R A T U R E O N C E N T R I C R E L A T I O N
even though they do not fulfil the requirements for
CR. Based on this approach, he recommended the use
of the term ‘adapted centric posture’ instead of CR if
there is TMJ disc derangement, although TMJs com-
fortably accept maximal compressive loading. His pa-
pers, although interesting with useful anatomic
information, are not usually supported by data and
statistics and they are rather personal views (Dawson,
1973, 1979, 1983, 1985, 1995, 1996). In a letter to the
Journal of Prosthetic Dentistry, George (1996) criticized
Dawson’s (1995) paper, stating that ‘… I believe it may
add to the confusion regarding dental occlusion and temporo-
mandibular joint (TMJ). The reasons are the definition used
for the term centric relation (CR) and the use of stylized
drawings instead of data or imaging to prove statements’.
The term retruded contact position continued (West-
ling, 1995) to be used erroneously. According to the
literature, this term should not be used for CR position
and if the first tooth contact in CR is meant to be used,
the term centric relation contact position (CRCP) is recom-
mended. Westling’s study focused on healthy adoles-
cents to determine the association between TMJ
sounds and first contacts in CR position. It was found
that reciprocal clicking had more significant relation-
ships with the signs and symptoms of TMD than other
TMJ sounds or than the sagittal distance and asymme-
try of RCP– ICP. The investigation also found no signs
indicating the unilateral contact in RCP to be an aetio-
logic factor of TMD.
Utz et al. (1995) compared two different CR records:
the Gothic arch tracing and check bite in the clinical
situation in 36 complete denture patients. Dentures
were remounted using one of the CR methods and the
occlusion corrected. The patients then wore the den-
tures for 2 – 3 weeks. An analogue questionnaire was
used to evaluate patient satisfaction. It was found that
those patients whose dentures were equilibrated with
the central-bearing point method tended to cope better
with their dentures and suffered, on average, from
fewer pressure spots. In this study, a computerized
custom-made Buhnergraph was used on a non-arcon
articulator§§. The measuring device and software were
designed by Dr. U. Wegmann at the University of
Bonn, Germany.
An orthodontist group (Hwang & Behrents, 1996)
designed a study to investigate the effects of orthodon-
tic treatment on centric discrepancy. Thirty-six or-
§§
Dentatus, Jakobsdalsvagen 6, Hagersten, Sweden.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013– 1023
1021
thodontic patients who had been treated with an
edgewise appliance were selected for the study, while
30 subjects who had no history of orthodontic treat-
ment were used as a control group. After recording CR
using a leaf gauge, centric prematurity and centric slide
were compared using a SAM 2 articulator and
mandibular position indicator. Results indicated that
the number of subjects with a prematurity was greater
in the control group; however, the number of subjects
with two or more prematurities and bilateral prematu-
rities was greater in the orthodontic treatment group.
The study concluded that orthodontic treatment does
not result in an increase in centric discrepancy. It is
necessary to add that an orthodontic group designed
this study. Only one of the results of the study is
supported by statistical analysis. Most figures and per-
centages are descriptive, and tabulated raw data, ex-
tracted from the subjects, were used as evidence.
Axiographic recording of the hinge axis in 262 pa-
tients (Celar et al., 1996) was used to compare two
mandibular positioning records: chin point guidance
and the final phase of deglutition. The authors’ aim
was to record the hinge axis, although these two meth-
ods have traditionally been used for CR records. Ap-
proximately half of the swallowing records were found
to be anterior and inferior to those of chin point guid-
ance and the records were significantly different from
each other. However, the replicability of both tech-
niques was similar, with the CPJ method being slightly
higher. The study concluded that the methods were
relatively coincidental, but that the variations of the
deglutition method in an anterior–inferior direction
questioned the clinical reliability of this method.
There is no doubt that CR is accepted by most clini-
cians and researchers as the most acceptable mandibu-
lar position to start with in reorganizing restorative or
orthodontic treatment. There is just one recent paper
(Sutcher, 1996) that discusses the contraindication of
restoration to CR. The paper has a fundamental mis-
conception, which assumes CR to be the most retruded
position and then describes a case report of construc-
tion to CR. There was just one patient reported in the
paper, where there were problems in constructing to
CR. When the record was made 9 mm anterior to CR,
the patient’s problems were solved.
Recently, Obrez & Stohler (1996) used the Gothic
arch tracing for the purpose of muscle pain and oc-
clusal dysfunction diagnosis. A single, blind random-
1022 A. KESHVAD & R. B. WINSTANLEY
ized study was designed to test whether pain can cause
significant changes in position of the mandible and,
therefore, form the basis for any perceived changes in
the maxillomandibular relationship. The second objec-
tive of the study was to determine whether pain could
cause changes in the mandibular range of motion. On
five subjects, tonic muscle pain was induced by infu-
sion of hypertonic saline solution into the masseter
muscle. Gothic arch tracings before and after injection
of the saline into the muscle were compared within the
subjects. Pain significantly affected the position of the
apex of the Gothic arch tracing in anterior and trans-
verse directions. The study concluded that there is a
relationship between pain and changes in occlusal rela-
tionship and questioned occlusal therapy as a treat-
ment directed towards the elimination of the
underlying cause in patients with masticatory muscle
pain.
In 1996, Dawson published another paper which
was mainly supported by his personal approach and
contained no data or statistics. The descriptive paper
recommended a new classification system for occlusion
that relates maximal intercuspation to the position and
condition of the TMJ. He commented that existing
classification systems for occlusion do not consider TMJ
position or condition when relating the mandibular
arch to the maxillary arch or the range of adaptive
changes that can affect the position of the condyles or
influence long-term occlusal stability. A recently intro-
duced term (Dawson, 1995), ‘adapted centric posture’,
was used in this classification to distinguish deformed
TMJs that have remodelled or adapted to a conforma-
tion that can comfortably accept maximal loading. The
following classification was recommended.
Type I. Maximal intercuspation occurs in harmony
with a verifiable CR.
Type II. Condyles must displace from a verified CR
for maximal intercuspation to occur.
Type IIA. Condyles must displace from adapted cen-
tric posture for maximal intercuspation to occur. (‘A’
refers to adapted.)
Type III. CR or adapted centric posture cannot be
verified. The TMJ cannot accept loading without
causing discomfort, so the relationship of maximal
intercuspation to correct condyle position cannot be
immediately determined. The condition is diagnosed
as transitory and treatable to achieve CR or adapted
centric posture.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013–1023
Type IV. The occlusal relationship is in a stage of
progressive disorder because of pathologically un-
stable and actively progressive deformation of the
TMJs. Type IV occlusion may be described specifi-
cally as (1) progressive anterior open occlusion, (2)
progressive asymmetry, or (3) progressive mandibu-
lar retrusion.
Campos, Nathanson & Rose (1996) used a combina-
tion of two CR methods (swallowing and Gothic arch
tracing) and two body positions (supine and upright)
to study condylar position and repeatability of the two
CR methods. Three interocclusal records were obtained
for each technique position combination for each of 30
patients. A custom-made three-dimensional analyser, a
kind of Buhnergraph, was used to compare the centric
records. They commented that because the swallowing
technique positioned the condyles in a more supero-
anterior position, this method was more reliable than
the Gothic arch tracing. However, the study indicated
no significant differences in reproducibility between
the two methods in any direction. Because of the fact
that both methods were repeatable but had different
condylar positions, they proposed ‘functional centric
area’ as opposed to point centric.
The number of CR studies in recent years has
dropped considerably. There were few studies in this
field in 1997. The first one, from Braun et al. (1997),
investigated the effects of an anterior programmer in
positioning the mandibular condyles. This study was
conducted with 19 healthy subjects. Two methods of
mandibular manipulation, with and without an ante-
rior leaf gauge, were used in the study. Rare earth
intensifying cephalometric radiographs were taken to
compare the condylar positions of different techniques.
The authors’ description is confusing in that it is not
clear whether they were recording hinge axis position
or CR position. Furthermore, the words ‘as posterior as
possible’ is not a correct definition for either of these
positions. The condylar centre of each image was com-
pared with the centre of the fossa in the cephalogram
and, therefore, the centre of the glenoid fossa was
considered as the ideal position for the condyle. The
study concluded that because only 10% of the records
showed an upward and forward condyle position, CR is
neither a functional nor a healthy position.
Another study (Tarantola, Becker & Gremillion
1997) by a group of members of the Pankey Institute
 A N A P P R A I S A L O F T H E L I TE R A T U R E O N C E N T R I C R E L A T I O N 1023

for Advanced Dental Studies in Florida, U.S.A., was
designed to evaluate the reproducibility of CR records.
Thirty-nine dentists randomly recorded CR once on five
patients and the records of the same patients were
compared with a Denar Centri-check™. Only one CR
method, BMM (Dawson 1989), was used in the study
and the results were tabulated using descriptive statis-
tics. The results indicated a variability of 0·1 mm, which
can be interpreted as the inter-operator error rather than
the repeatability of the method. A wax record without
relining material and anterior deprogrammer were used
for records. The investigators proposed that CR could
become a predictable, repeatable starting point for oc-
clusal therapy. It should also be considered as a starting
point for various research projects that correlate the
relationship between occlusion and various TMDs.
To be continued.
Correspondence: R. B. Winstanley, Department of Restorative
Dentistry, School of Clinical Dentistry, University of Sheffield,
Sheffield, S10 2TA, U.K. E-mail: r.winstanley@sheffield.ac.uk

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 1013– 1023