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Clinical application of a maximum intercuspal position-centric relation

occlusion conversion of a lateral cephalogram in the treatment of orthodontic
patients

Article · April 2021

DOI: 10.1016/j.xaor.2021.04.001

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CLINICAL TECHNIQUES

Clinical application of a maximum

intercuspal position-centric relation
occlusion conversion of a lateral
cephalogram in the treatment of
orthodontic patients
Jae Hyun Park,a Sang Mi Lee,b Da Nal Moon,b and Gye Hyeong Leec
Seoul, South Korea, and Gwangju, South Korea

Evaluation of condylar position is a critical step in orthodontic diagnosis. Diagnosis using an articu-
lator-mounted model helps orthodontists establish an orthodontic treatment plan on the basis of
centric relation occlusion (CRO). The quantitated condylar position obtained from an articulator can
be transferred to a lateral cephalogram taken in maximum intercuspal position (MIP) using a MIP-
CRO conversion technique. This article details the step-by-step procedure with comprehensive illus-
trations for applying MIP-CRO conversion for diagnosis. The results of the MIP-CRO conversion
provide a more accurate and predictable orthodontic treatment plan. (Am J Orthod Dentofacial
Orthop Clin Companion 2021;1:127-135)

Dr. Jae Hyun Park Dr. Sang Mi Lee Dr. Da Nal Moon Dr. Gye Hyeong Lee

a
Postgraduate Orthodontic Program, Arizona School of Dentistry Department of Orthodontics, Graduate School of Dentistry,
& Oral Health, A.T. Still University, Mesa, Ariz; International Chonnam National University, Gwangju, South Korea.
Scholar, Graduate School of Dentistry, Kyung Hee University,
All authors have completed and submitted the ICMJE Form for
Seoul, South Korea.
Disclosure of Potential Conflicts of Interest, and none were
b
Graduate School of Dentistry, Chonnam National University, reported.
Gwangju, South Korea; College of Medicine, The Catholic Univer-
Address correspondence to: Jae Hyun Park, Postgraduate
sity of Korea, Seoul, South Korea.
Orthodontic Program, Arizona School of Dentistry & Oral Health,
c
Roth Orthodontic Society, and Department of Orthodontics, A.T. Still University, 5835 E Still Circle, Mesa, AZ 85206; e-mail,
School of Dentistry, Kyung Hee University, Seoul, South Korea; jpark@atsu.edu

August 2021, Vol 1, Issue 2 127

Park et al.
Since Broadbent’s great achievement in the 1930s,
cephalometric radiographies with dental models have
been used as standard diagnostic tools by orthodontic
professionals. Obviously, they can provide a substantial
amount of information for planning orthodontic and/or
orthognathic treatment and have been questioned whether
they could offer a true relationship of the mandible to the
patient’s maxilla. There are often discrepancies in the
mandibular position between the centric relation and max-
imum intercuspal positions (MIP), especially in patients
with malocclusions. This condition appears as discrepan-
cies between centric relation occlusion (CRO) and MIP at
the occlusion level.1-3 The terms of the different positions
of the condyle and the occlusions have been changed, so
we referred to the ninth edition of the Glossary of Prostho-
dontic Terms, which is the most recently updated by the
Academy of Prosthodontics.4 When a patient shows a large
MIP-CRO discrepancy, an orthodontic treatment plan must
be reconsidered from the diagnostic stage. If a significant
MIP-CRO discrepancy is found in the middle of orthodontic
treatment, the patient’s dental relation can be seriously
altered, so finishing becomes complicated and the treat-
ment period is prolonged.5,6
After long debates about the relationship between the
mandibular position and its function, it is now clear that
treatment on the basis of centric relation of the mandible
is physiologically more stable, increases the efficiency of
the patient’s neuromuscular system, and reduces the
potential for dysfunction of the temporomandibular sys-
tem.7-10 Much research has concluded that the treatment
on the basis of the centric relation is essential for coordi-
nation of occlusion and the temporomandibular joint.11-14
On the occlusion level, a patient’s CRO position can be
demonstrated by using a semiadjustable articulator. How-
ever, a lateral cephalogram, one of the main orthodontic
diagnostic tools, is mostly taken with the mandible in MIP.
This is not so critical in patients showing little MIP-CRO dis-
crepancy, but when patients have a large MIP-CRO dis-
crepancy, simply taking a lateral cephalogram in MIP is not
sufficient to represent the genuine position of the mandi-
ble, and significant error might be introduced in the treat-
ment planning. When faced with patients having large MIP-
CRO discrepancies, clinicians might be prone to think that
it is not practical to take a cephalometric radiograph of
the patient’s mandible positioned in centric relation. In
response to this, some researchers have developed techni-
ques to transform head films taken in MIP into those in
CRO. This process is well known as the MIP-CRO conver-
sion of a lateral cephalogram.
Wood5 introduced a technique for transferring centric
relation measurements to a lateral cephalogram. It advo-
cated a significant difference between the cephalometric
128
measurements from MIP tracings and those from CRO trac-
ings. Later, Slavicek15 developed a method for transferring
the clinical information obtained from a mounted model to a
cephalometric radiograph. This technique permitted the
transformation of a headfilm tracing in the MIP state into the
CRO state. When Shildkraut et al13 compared cephalometric
measurements derived from a MIP tracing with those from a
converted CRO tracing, the results showed a significant dif-
ference between them for most cephalometric values. A rela-
tively recent study by Park et al16 investigated whether there
were substantial differences between cephalometric meas-
urements from MIP tracings compared with those from con-
verted CRO tracings and suggested that CRO should be the
starting point for proper diagnosis and treatment planning.
Unfortunately, the detailed MIP-CRO conversion pro-
cess is not fully understood despite many pioneering
endeavors. It seems to have not been standardized enough
to be applied among many clinicians, although they agree
with its importance and value. This article suggests a tool
that helps orthodontic professionals conduct accurate
maxillomandibular functional analysis by documenting a
technique for MIP-CRO conversion with the report about a
case in which this process affected the treatment planning
and result of treatment.
CASE REPORT
A 22-year-old female patient presented with concerns
about her anterior protrusion. Clinical examination revealed
incompetent lips and a convex profile with mild-to-moderate
crowding in her maxillary and mandibular arches. A pan-
oramic radiograph showed slightly flattened condylar heads
on both sides, but the continuity of the cortical layer covering
the condylar head was found without breaking the cortica-
tion. Lateral cephalometric analysis indicated a mild skeletal
Class II (ANB, 5.5°) with a slightly retrognathic mandible. Her
maxillary and mandibular incisors were proclined (U1-SN,
116.0°; IMPA, 108°) (Fig 1, A and B; Table).
The patient did not report any temporomandibular dis-
order (TMD) symptoms, but she showed a dual bite during
the clinical examination, indicating that she had a MIP-CRO
discrepancy. Her dental models were mounted on a semi-
adjustable articulator to visualize and determine the quan-
titative amount of MIP-CRO discrepancy (SAM Praezision-
Stechnik GmbH, M€ unchen, Germany), and the mandibular
position indicator (MPI) of the SAM III articulator was used.
MPI is a device that registers the 3-dimensional position of
the mandible in relation to the cranium. The magnitude
and direction of the condylar position changes can be
measured with the MPI, which permits the clinician to eval-
uate the directional displacement and its magnitude in the
condylar level from centric relation to MIP.17 In this patient,
the MPI measurements showed a downward and forward
condylar distraction on both sides (Fig 1, C). This
AJO-DO CLINICAL COMPANION
 Park et al.

Fig 1. Pretreatment records: A, facial and intraoral photographs; B, lateral cephalogram and panoramic radiograph; C, pretreatment
dental models mounted in CRO and the MPI data. MPI data shows MIP-CRO discrepancies at the joint level. The red and blue dots
indicate the CRO and MIP, respectively, and the result presented a downward and forward direction of condylar distraction.

August 2021, Vol 1, Issue 2 129

Park et al.

Table. Cephalometric measurements

Measurement Korean norm Pretreatment Conversion Posttreatment

SNA (°) 82.0 84.5 84.5 84.5

SNB (°) 79.0 79.0 78.0 78.0

ANB (°) 2.5 5.5 6.5 6.5

Saddle angle (°) 126.0 114.0 115.0 115.0

Articular angle (°) 149.0 168.0 166.0 166.0

Gonial angle (°) 118.5 115.0 115.0 115.0

Upper gonial angle (°) 45.0 36.0 37.0 37.0

Lower gonial angle (°) 74.0 79.0 78.0 78.0

SUM (°) 393.0 397.0 396.0 396.0

Facial angle (°) 89.0 85.0 84.0 84.0

Wits (mm) -2.5 0.0 0.5 0.5

SN-MP (°) 33.5 37.0 36.0 36.0

Ramus height (mm) 51.5 54.0 52.0 52.0

Post.FH/Ant.FH (%) 66.8 66.0 66.5 66.5

U1-SN (°) 104.0 116.0 116.0 100.0

U1-FH (°) 116.0 121.5 121.5 106.0

U1-NA (°) 22.0 31.0 31.0 15.5

U1-NA (mm) 4.0 7.5 7.5 1.0

IMPA (°) 90.0 108.0 108.0 97.0

L1-NB (°) 25.0 43.0 43.0 32.0

L1-NB (mm) 6.0 13.0 13.0 9.0

U1/L1 (°) 124.0 99.0 99.5 125.0

Overjet (mm) 2.8 2.5 5.0 3.0

Overbite (mm) 3.0 2.5 2.5 2.5

Upper lip (mm) 0.0 0.5 1.0 1.0

Lower lip (mm) 0.0 5.5 4.5 2.0

discrepancy in the joint level ought to have been increased
at the occlusion level. The premature tooth contact in the
posterior area could significantly change the mandibular
position, which affects the cephalometric measurements.
A MIP-CRO conversion was performed to transfer the cen-
tric relation information using the patient’s MPI readings to
the lateral cephalogram taken in MIP.
Two records are essential for MIP-CRO conversion; a
lateral cephalogram taken in MIP and dental models
mounted in CRO with their MPI data. Following is the
detailed process for making a MIP-CRO conversion.
1. Cephalometric tracing in MIP.
The MIP-CRO conversion starts with cephalometric trac-
ing in MIP. Trace the lateral cephalogram with a black
line (Fig 2, A).
2. Construct the axis-orbital plane and mark the esti-
mated hinge axis.
A common reference plane between the lateral cephalo-
gram and the articulator-mounted dental model must
be established to convert a lateral cephalogram taken
in MIP into the CRO state. As the reference plane of the
mounted model on the SAM III articulator is the axis-
orbital plane, transferring this plane to the lateral

130 AJO-DO CLINICAL COMPANION

 Park et al.

Fig 2. Process of the MIP-CRO conversion: A, cephalometric tracing in MIP; B, construct the axis-orbital plane and mark the estimated
hinge axis; C, mark the horizontal (D x) and vertical (D z) average readings (1.6,1.6) of the right (1.4,1.3) and left (1.8,1.9) sides on a
data record sheet; D, draw the overbite line and copy the mandibular structures in green and mark the estimated hinge axis as a green
dot on the new tracing paper; E, mark the CRO axis on the MIP tracing; F, superimpose the mandibular structure; G. Result of MIP-
CRO conversion.

cephalogram is the first step. Therefore, draw the Frank-
fort horizontal plane (FH plane, in blue) and measure
6.5° down from the FH plane and draw another line
(orange) with the orbitale as a starting point. This line is
called the axis-orbital plane. Statistically, the axis-
orbital plane is found to be inclined 6.5° down from the
FH plane in Caucasians.13 This plane is coordinated with
the line that connects the center of the condyle ball and
the base of the upper member in the SAM III articulator,
which has an identical orientation with the face-bow
transfer.
The next step is to locate and mark the estimated
hinge axis on the MIP tracing as one-third of the con-
dyle's width from the anterior aspect of its axis-orbital
plane, which will be the rotational center of the con-
dylar movements (Fig 2, B).
3. Mark the horizontal (Dx) and vertical (Dz) average
readings on a data record sheet.
For the horizontal plane (Dx), the value is recorded as
positive when the MIP (blue dots) is anterior to the
CRO (red dots). For the vertical plane (Dz), the value
is recorded as positive when the MIP is inferior to the
CRO. The mean value of MPI readings on the right and
left sides needs to be calculated to simulate the effect
on a midsagittal plane. Mark this mean value on a
new data record sheet, a condylar position indicator
(CPI) data record sheet (Panadent Corporation, Calif),
which is 110% of the MPI graph papers’ size to match
the magnification of the cephalometric radiograph. At
this stage, note that the positive values (+) are
directed toward the upper left side of the data record
sheet, which is opposite to the MPI system graph
paper, as the right side of the patient’s head is
observed in the lateral cephalogram and the CRO
is seated more superiorly than the MIP by definition
(Fig 2, C).
4. Draw the overbite line and copy the mandibular
structures.
To register the vertical dimension, draw a short hori-
zontal line (red) passing through the incisal edge of
the mandibular incisor. This line should be parallel to
the functional occlusal plane. On a new piece of trac-
ing paper, copy the entire mandibular structures,
including the overbite line, in green or any other dis-
tinct color. And mark the estimated hinge axis as a
green dot on the new tracing paper (Fig 2, D).
5. Mark the centric relation axis on the MIP tracing.
Overlay the data record sheet on the MIP tracing
where the estimated hinge axis and axis-orbital plane
pass through. Then mark the new hinge axis on the

August 2021, Vol 1, Issue 2 131

Park et al.

Fig 3. Cephalometric superimposition: A, black, pretreatment; blue, the result of VTO with MIP tracing is applied; B, black,
pretreatment; green, the result of VTO with CRO tracing after MIP-CRO conversion is applied; C, comparison of treatment planning on
anchorage management of mandibular teeth. The results indicated that when CRO tracing (green) is applied, further mesial
movement of the mandibular posterior teeth is required than one with the MIP tracing (blue); D, treatment progress.

MIP tracing with the blue dot. This blue dot will be the
centric relation axis. (Fig 2, E).
6 and 7. Superimpose the mandibular structures.
Superimpose the green dot (estimated hinge axis) of the
copied (green) tracing on the blue dot (centric relation
axis) of the first (black) tracing (Fig 2, F). Then rotate the
copied tracing on this centric relation axis as a rotation
center to the best superimposition of the overbite line
(Fig 2, G).
In this patient, the result of the MIP-CRO conversion
indicated that the patient’s mandible was rotated clock-
wise as the condyles were seated into the CRO positions,
resulting in a more severe skeletal Class II pattern with a
larger overjet (ANB, 6.5°; Overjet, 5.0 mm). If we had used
the cephalometric analysis taken in MIP, we would have
suggested that this patient needed a full fixed orthodontic
treatment with the maxillary second molar extraction,
which had root canal treatment and showed secondary
caries and the mandibular first premolars.
According to the visualized treatment objective (VTO) with
the cephalometric analysis after MIP-CRO conversion; how-
ever, more active mesial movement of her mandibular
molars should be planned to compromise the Class II molar
relation. With the rediagnosed data after MIP-CRO conver-
sion, the treatment plan was altered to extract maxillary and
mandibular second premolars for minimum anchorage prep-
aration of the mandibular teeth (Fig 3, A-C; Table).
Full fixed 0.022-in preadjusted edgewise orthodontic
appliances (Avex; Opal Orthodontics, Utah) were bonded
on her arches for leveling and alignment. Two temporary
skeletal anchorage devices (diameter, 1.4 mm; length, 8
mm; Orlus, Seoul, Korea) were placed in the buccal alveo-
lar bone between the roots of the maxillary molars for

132 AJO-DO CLINICAL COMPANION

 Park et al.

Fig 4. Posttreatment records: A, facial and intraoral photographs; B, lateral cephalogram and panoramic radiograph; C,
cephalometric superimposition. Black, pretreatment; red, posttreatment.

retraction of the anterior segments (Fig 3, D). The total
treatment time was 24 months.
Posttreatment analysis indicated that proper overbite and
overjet had been achieved, and the maxillary and mandibu-
lar incisors showed normal inclination (U1-SN, 100.0°; IMPA,
97.0°). The patient’s protrusive and incompetent lips were
significantly improved as a result of anterior retraction
(Fig 4, A-C; Table). Three years later, the results were still
stable. The condylar movement was smooth with mouth

Fig 5. Three-year posttreatment intraoral photographs.

August 2021, Vol 1, Issue 2 133

Park et al.
opening and closing, and no other temporary mandibular
joint (TMJ) symptoms were observed (Fig 5).
DISCUSSION
It is indisputable that an understanding of the mandibu-
lar position is important for orthodontic treatment plan-
ning. Consequently, any conditions that could cause a
change in the condyle position have attracted great inter-
est among orthodontists. Degenerative changes in TMJs
can be one of the essential etiologic factors for a change in
condylar position. TMD causes a degenerative change of
the TMJs with lysis and repair of the articular fibrocartilage
and underlying subchondral bone. The changes at the con-
dylar level may consequently result in skeletal and facial
characteristics.18,19
Some patients without degenerative changes in their
TMJ structure might still present a mandible position
change and the MIP-CRO discrepancy. If an occlusal inter-
ference exists in an orthodontic patient for any reason, the
protective co-contraction in their masticatory system is
more likely to occur. The process of muscle engram can
alleviate this. However, it often degenerates into the con-
dylar position changes caused by contraction of the lower
lateral pterygoid muscles and hyperactivation of the sur-
rounding elevator muscles. When etiologic factors are
relieved, and the adverse protective co-contraction is
gone, the condyles move to the superoanterior position in
the articular fossae, resting against the posterior slopes of
the articular eminences. This position is naturally guided
by the vector sum of the three major elevator muscles,
masseter, temporalis, and medial pterygoid muscles, and
is regarded as a musculoskeletally stable position.20-22 If
this happens during orthodontic treatment, significant
changes in the occlusion and sometimes even facial char-
acteristics can occur, which may cause the orthodontist to
panic. Therefore, evaluation of the condylar position is crit-
ical for having reliable information about a patient's occlu-
sion and definitive criteria for an accurate diagnosis.
The use of an articulator in evaluating condylar position
has been the first choice for orthodontic diagnosis because
previous studies proved that dental models mounted on
the articulator helped clinicians understand the
Fig 6. Process of the MIP-CRO conversion in Quick Ceph Studio.
134
mandibular position in CRO from which position the man-
dible can move and function without harmful neuromuscu-
lar influence.23,24 Many other reports also demonstrated
that the evaluation of the condylar position with MPI is supe-
rior to the use of radiographs or other imaging devices and is
excellent for quantification of the condylar position change in
3-dimensions.15,25,26 As taking a cephalometric radiograph of
a patient’s mandible positioned in CRO is practically almost
not possible, the technique to transform a lateral cephalo-
gram taken in MIP into one in CRO is an important step in
representing the true condylar position in a headfilm.
With the patient featured in this article, the result of the
MIP-CRO conversion indicated that her mandible was
rotated clockwise so that the dental relationship would
have consequently been changed to a more Class II rela-
tion. When it is expected that this change will be drastic, a
stabilization splint may be used before any active ortho-
dontic tooth movement. The stabilization splint works with
an ideal occlusal scheme and decreases abnormal muscle
activity and the protective co-contraction of the muscles
so that a stable condyle position can be achieved. In addi-
tion, the use of a stabilization splint promotes the forma-
tion of a pseudodisc on the posterior band of the disc,
which helps the condyle seat in the most forward and
uppermost position in the articular fossa.9,14,22
However, in this patient, we did not use a stabilization
splint as we concluded that the patient’s mandibular
change would not be too radical on the basis of the result
of the MIP-CRO conversion. Instead, it helped us decide to
extract two mandibular second premolars rather than the
first premolars: the result of the MIP-CRO conversion
instructed us to have more mesial movement of the man-
dibular molars. We had to extract her maxillary second
premolars because the maxillary right second premolar
had undergone root canal therapy and had a massive pros-
thetic restoration, and now both showed secondary caries,
so their prognosis was not good. We were ready to use
miniscrews in the maxillary posterior area to achieve maxil-
lary maximum anchorage management.
For many years, clinicians have used digital cephalo-
metric radiographs and cephalometric analysis systems.
We introduced the MIP-CRO conversion process on a hand
AJO-DO CLINICAL COMPANION

drawing basis as we thought it would offer the readers
a better understanding of the step-by-step graphic illustra-
tions. However, some popular digital cephalometric analy-
sis systems provide digital MIP-CRO conversion. For
instance, Quick Ceph Studio (Quick Ceph Systems, San
Diego, Calif) and Dolphin Ceph Tracing (Dolphin Imaging &
Management Solutions and Management Solutions, Chats-
worth, Calif) are the most widely used imaging and analysis
programs that offer MIP-CRO conversion functions by only
fillings in the blanks with MPI data and few more clicks
(Fig 6). When using this system, clinicians often fail to cor-
rectly register the hinge axis, which will be the rotation
center of the condylar movements. The most common mis-
take is positioning the hinge axis on the center of the con-
dylar head. As we discussed earlier, the hinge axis should
be marked as a point that is one-third of the width of the
condyle from its anterior aspect of the axis-orbital plane,
6.5° down from the FH plane.
CONCLUSIONS
In the diagnosis and treatment of orthodontic patients,
evaluations of condylar position gained their importance,
and CRO should be the starting point of mandibular move-
ment and orthodontic diagnosis. The CRO quantitated with
an articulator can be transferred to a lateral cephalogram
taken in MIP with the MIP-CRO conversion technique. This
can provide orthodontists with accurate and reliable
orthodontic diagnostic criteria to establish more predict-
able orthodontic treatment plans.
AUTHOR CREDIT STATEMENT
Jae Hyun Park contributed to writing the manuscript
and critical revision of the manuscript; Sang Mi Lee con-
tributed to writing the manuscript; Da Nal Moon contrib-
uted to writing the manuscript; and Gye Hyeong Lee
contributed to treating the patient.
Supplementary materials
Supplementary material associated with this article can
be found in the online version at doi:10.1016/j.xaor.2021.
04.001.
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