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Centric relation

Centric relation (CR) is defined as the maxillomandibular relationship, independent of tooth contact, in which the condyles articulate in the anterior-superior position against the posterior slopes of the articular eminences.^[1] In this position, the mandible is restricted to a purely rotary movement about the condyles, serving as a clinically useful and repeatable reference position for mounting dental casts in prosthodontic procedures.^[1] This bone-to-bone relationship emphasizes the positioning of the mandibular condyles within the temporomandibular joints (TMJs), with the articular discs interposed, and is reproducible through mandibular manipulation in the absence of pathology.^[2] The concept of centric relation has evolved significantly since its introduction in the early 20th century, reflecting advances in understanding TMJ anatomy and function.^[2] Early definitions, such as those from the 1920s and 1930s, described it as the "most retruded unstrained position" of the mandible, focusing on a posterior-superior condylar placement.^[2] By the late 20th century, influenced by imaging studies like arthrography and MRI, the emphasis shifted to an anterior-superior condylar position against the articular eminences, as codified in the Glossary of Prosthodontic Terms (GPT) editions from the 1980s onward.^[3] Despite this progression, over 26 definitions have been proposed historically, leading to ongoing debates about its precise anatomical and physiological basis.^[2] In clinical dentistry, particularly prosthodontics and restorative procedures, centric relation is essential for establishing stable occlusion and preventing temporomandibular disorders (TMDs).^[4] It provides a reliable starting point for recording jaw relations during treatments like complete dentures, crowns, or orthodontics, ensuring that restorations align with the patient's physiologic joint position to minimize muscle strain and occlusal interferences.^[5] Disharmonies between centric relation and centric occlusion—the tooth-to-tooth contact in maximum intercuspation—can contribute to TMD symptoms, wear, or prosthetic failure, underscoring the need for accurate recording techniques such as bimanual manipulation or leaf gauges.^[3] However, its biological validity remains controversial, as TMJ morphology varies individually and adapts over time, challenging the notion of a universal "ideal" position.^[4] Contemporary perspectives highlight centric relation's utility as a therapeutic reference rather than a diagnostic tool, with calls for terminology updates to reflect its practical rather than anatomical focus.^[4] Recent studies emphasize patient-specific adaptations and the integration of digital technologies for more precise recordings, aiming to resolve historical inconsistencies.^[6] While not indicative of TMD etiology, proper management of centric relation supports long-term oral health outcomes in rehabilitative dentistry.^[4]

Definition and Terminology

Core Definition

Centric relation (CR) is defined as the maxillomandibular relationship, independent of tooth contact, in which the condyles articulate in the anterior-superior position against the posterior slopes of the articular eminences, with the articular discs interposed at the thinnest avascular portion between the condyles and the glenoid fossae, and the ligaments in a relaxed state.^[7] This position represents an unstrained, physiologic alignment of the jaws, restricted to purely rotary movement about the transverse horizontal axis, from which the mandible can initiate vertical, lateral, or protrusive excursions.^[7] Key characteristics of centric relation include its high reproducibility as a clinically determined position, making it a reliable reference for occlusal analysis and treatment planning independent of dental contacts.^[7] It serves as a foundational reference position for achieving occlusal stability, applicable to patients with or without teeth, and is discernible through superior and anterior guidance of the mandible.^[7] The term "centric relation" originates from "centric," implying a central or reference jaw position, and "relation," denoting the interrelationship between the maxilla and mandible. This concept is structurally based on the anatomy of the temporomandibular joint (TMJ), where the condyle-disk assemblies achieve optimal positioning within the glenoid fossa and articular eminence.^[7] Centric relation (CR) serves as a foundational reference in occlusal analysis, distinguished primarily by its independence from dental contacts and focus on condylar positioning within the temporomandibular joint (TMJ).^[2] A key distinction exists between CR and centric occlusion (CO). CR represents a bone-to-bone relationship, where the mandibular condyles are positioned in their most anterosuperior unstrained location in the glenoid fossae, without reliance on posterior tooth interference.^[2] In contrast, CO describes the specific occlusal contact achieved when the mandible is in CR, involving tooth-to-tooth intercuspation under this condylar alignment; however, in clinical practice, CO is often conflated with habitual bite positions that may not align perfectly with CR.^[6] This separation underscores CR's role as a stable, repeatable posterior determinant, while CO emphasizes the resulting dental harmony.^[8] CR also differs from maximum intercuspation position (MIP), which is entirely tooth-driven. MIP occurs when the maxillary and mandibular teeth achieve complete intercuspation, regardless of condylar placement, and can vary due to factors such as tooth wear, misalignment, or habitual shifts.^[8] Unlike CR's condyle-centered stability, MIP prioritizes maximal dental engagement, potentially leading to discrepancies if condyles are displaced posteriorly or laterally during closure.^[2] These differences highlight CR as a reliable starting point for occlusal therapy, whereas MIP serves as an endpoint influenced by dentition.^[8] Historically, the term retruded contact position (RCP) preceded modern CR usage, referring to the initial tooth contacts occurring at the most posterior condylar position during mandibular retraction.^[2] Early 20th-century definitions emphasized this retruded alignment (e.g., from 1929 to the 1970s), but evolving TMJ research shifted focus to an anterosuperior condylar position by the 1980s, rendering RCP a precursor concept now viewed as potentially strained and less physiologically accurate.^[2] This terminological evolution reflects over a century of refinement in understanding jaw relations.^[2]

Anatomy and Biomechanics

Temporomandibular Joint Components

The temporomandibular joint (TMJ) comprises several key anatomical components that facilitate its function as a synovial hinge and gliding joint between the mandible and temporal bone. The glenoid fossa, a concave depression in the inferior aspect of the temporal bone, serves as the superior articulating surface for the mandibular condyle, providing a stable housing that is wider mediolaterally than anteroposteriorly to enhance joint congruence.^[9] Anterior to the glenoid fossa lies the articular eminence, a prominent bony ridge that guides condylar translation during jaw movements and contributes to the joint's load-bearing capacity.^[9] The mandibular condyle, an ovoid process at the superior end of the mandible measuring approximately 15-20 mm transversely and 8-10 mm anteroposteriorly, forms the inferior articulating surface and is covered by fibrocartilage to withstand compressive forces.^[9] Interposed between the condyle and glenoid fossa is the articular disc, also known as the meniscus, a biconcave fibrocartilaginous structure about 2 mm thick anteriorly and 3 mm posteriorly that divides the joint into superior and inferior compartments, thereby permitting independent rotational and translational motions while distributing loads evenly.^[9] The synovial membrane lines the inner surface of the joint capsule, secreting synovial fluid to lubricate the articulating surfaces and nourish the avascular disc and cartilage, which is essential for frictionless movement and joint health.^[9] Supporting ligaments provide passive stability to the TMJ, limiting excessive motion and maintaining component alignment. The temporomandibular ligament, a thickening of the lateral joint capsule, consists of outer oblique and inner horizontal fibers that restrict mandibular distraction, protrusion, and posterior displacement.^[9] Collateral ligaments, also termed medial and lateral discal ligaments, attach the articular disc to the poles of the mandibular condyle, ensuring the disc remains properly positioned relative to the condyle during joint function.^[9] The capsular ligament encircles the entire joint, reinforcing the synovial membrane and contributing to overall containment and stability by resisting tensile forces.^[9] In centric relation, the mandibular condyles are seated in their most anterosuperior position within the glenoid fossa, with the articular disc properly interposed and aligned between the condyle and fossa, with the posterior band of the articular disc positioned between the condyle and glenoid fossa to ensure proper alignment and congruence.^[6] This relationship achieves optimal alignment of the TMJ components, serving as a reproducible reference for mandibular positioning.^[6] The ligamentous structures play a crucial role in maintaining stability during centric relation by guiding the condyle into its superior position and restricting deviations, with the collateral and capsular ligaments particularly ensuring disc-condyle cohesion to avoid misalignment under load.^[6]^[9]

Biomechanical Role in Occlusion

Centric relation (CR) represents a stable, reproducible maxillomandibular position where the condyles are seated in their most anterior-superior location within the glenoid fossae, independent of tooth contacts, and guided primarily by the temporomandibular ligaments to ensure minimal joint loading. This positioning allows the mandible to articulate with the thinnest avascular portion of the articular discs against the posterior slopes of the articular eminences, promoting a purely rotary hinge movement without translatory components that could induce uneven stresses.^[1] By unloading the joint structures and avoiding ligamentous tension, CR facilitates balanced force distribution across the masticatory system, reducing the risk of degenerative changes in the temporomandibular joint (TMJ).^[10] In relation to occlusion, CR serves as a foundational reference for achieving harmonious tooth contacts, where occlusal forces are evenly distributed to prevent lateral shifts or deflective interferences during closure. When the mandible is positioned in CR, elevator muscles such as the masseter and temporalis exhibit minimal contraction, enabling relaxed neuromuscular coordination and reproducibility across multiple recordings.^[1] This physiological alignment minimizes muscle hyperactivity by eliminating strain from aberrant positions, thereby supporting efficient masticatory function and long-term occlusal stability.^[10] For instance, aligning occlusal schemes within approximately 1 mm of CR helps avoid premature contacts that could otherwise lead to uneven loading on individual teeth or the TMJ.^[10] The physiological basis of CR lies in its unstrained state, where muscle activity is at a baseline level, allowing the ligaments and joint capsules to guide the condyles without extraneous forces. This position, often described as the terminal hinge relation, ensures that subsequent mandibular excursions—such as protrusion or laterotrusion—originate from a neutral baseline, promoting overall biomechanical harmony in the occlusion.^[1] Studies emphasize that deviations from CR can increase joint and muscular stresses, underscoring its role in maintaining homeostasis within the stomatognathic system.^[10]

Clinical Significance

Applications in Prosthodontics

In complete denture fabrication, centric relation (CR) serves as a fundamental reference position for establishing the vertical dimension of occlusion and orienting the occlusal plane, which are essential for achieving denture stability and functional harmony with the stomatognathic system. By recording CR through methods such as interocclusal wax or Gothic arch tracing, clinicians transfer this position to an articulator to set the vertical dimension using mechanical and physiological approaches with occlusal bite rims, ensuring that artificial teeth are arranged to direct occlusal forces toward the alveolar ridges without deflective contacts. This approach, as seen in concepts like lingualized occlusion, centralizes vertical forces on the mandibular teeth and maintains a flat occlusal plane parallel to the denture foundation, thereby minimizing tipping and enhancing stability during mastication and swallowing. The reproducibility of CR is particularly valuable here, as it provides a consistent, patient-specific baseline independent of tooth contacts. In fixed prosthodontics, CR guides the placement of crowns and bridges by serving as the most stable and repeatable temporomandibular joint position, helping to eliminate occlusal interferences and promote long-term occlusal health. During treatment planning, bimanual manipulation or deprogramming devices are used to capture CR, followed by diagnostic wax-ups and provisional restorations that verify functional harmony and minimize postoperative adjustments. Equal simultaneous contact of posterior teeth in centric occlusion aligned with CR prevents uneven force distribution, reduces stress on supporting structures, and avoids deflective forces that could lead to restorative failure or temporomandibular disorders. This organized approach to occlusion in CR ensures that cuspal inclines allow smooth gliding into eccentric positions without interferences, contributing to the longevity of fixed prostheses. For edentulous patients, CR offers a tooth-independent reference that is crucial for prosthetic success, as it prevents denture instability and associated discomfort by establishing bilateral balanced occlusion without reliance on existing dentition. Fabricating dentures with simultaneous posterior tooth contacts in CR and eccentric positions minimizes horizontal and rotational stresses on resorbed ridges, reducing issues like tissue trauma, reduced bite force, and ulceration that compromise patient comfort during daily functions. Studies indicate that accurate CR records significantly lower the need for prosthetic modifications, such as adding artificial teeth, thereby enhancing overall stability and satisfaction in complete denture wearers.

Role in Orthodontics and TMD Diagnosis

In orthodontics, the role of centric relation (CR) remains controversial despite its historical use as a reference for evaluating mandibular positioning. Although some approaches incorporate CR to assess skeletal relationships in malocclusions like Class II and Class III, scientific evidence does not strongly support its routine application in guiding appliance design or minimizing relapse risks.^[11] CR's utility in temporomandibular disorder (TMD) diagnosis is limited, as condylar position in CR is not considered diagnostic of underlying joint pathologies according to evidence-based reviews. Deviations between CR and maximum intercuspation, measured as condylar displacement, tend to be greater in symptomatic individuals—averaging approximately 1.5-1.7 mm vertically and 0.4 mm transversely—compared to asymptomatic controls, but these differences do not reliably indicate specific issues like disc displacement or muscle spasm.^[12] Symptomatic TMD cases may show bilateral inferior-distal shifts correlating with myofascial pain, while the distinction from centric occlusion helps identify potential joint discrepancies, though CR's diagnostic value is debated.^[11] Therapeutically, positioning the mandible in CR via stabilization splints is a cornerstone of TMD management, redistributing occlusal forces to seat the condyles superiorly and alleviate symptoms such as pain and limited function. Centric stabilization splints, fabricated to maintain CR, demonstrate moderate-to-large short-term pain reduction (standardized mean difference of 0.75) and improved mandibular mobility, outperforming counseling or soft splints in myogenous TMD cases. This approach not only reduces muscle spasm but also restores joint stability, with significant pain relief observed across studies.^[13]

Recording Methods

Manual Guidance Techniques

Manual guidance techniques for recording centric relation (CR) rely on the clinician's hands-on manipulation of the patient's mandible to position the condyles in their most superior-anterior location within the temporomandibular joint (TMJ), ensuring muscle relaxation and reproducibility without the need for mechanical devices.^[14] These methods emphasize deprogramming the neuromuscular system, often through techniques like using a cotton roll or jig to eliminate occlusal interferences, allowing the mandible to assume a stable, retruded position.^[15] Bimanual manipulation, also known as Dawson's technique, involves the clinician using both hands to stabilize and guide the patient's mandible. The clinician places their thumbs bilaterally on the patient's chin while supporting the posterior mandible with their fingers, applying gentle posterior and superior pressure to seat the condyles against the posterior slopes of the articular eminences.^[14] This bilateral approach promotes symmetric muscle relaxation, particularly of the lateral pterygoid muscles, and is considered highly reproducible for capturing CR in both dentate and edentulous patients.^[15] Chin-point guidance employs a unilateral hand placement where the clinician rests their thumb on the midline of the patient's chin and applies controlled posterior force to retract the mandible while the patient swallows or lightly closes. This technique relaxes the suprahyoid muscles and elevators, facilitating condylar seating in the glenoid fossa without excessive force that could distort the recording.^[14] It is particularly useful in cases of limited mouth opening or when bilateral access is challenging, though it may introduce slight asymmetries if not performed symmetrically.^[15] Tongue positioning aids CR recording by leveraging the tongue's role in mandibular stabilization and muscle deprogramming. The patient is instructed to extend the tongue tip to the junction of the hard and soft palates (or posterior border of the hard palate), maintaining this contact while slowly closing the mandible until initial tooth contact occurs.^[15] This method, based on the linguomandibular homotrophy concept, minimizes deviations from the maximal intercuspal position and enhances reproducibility by reducing anterior muscle pull.^[15]

Device-Assisted Approaches

Device-assisted approaches to recording centric relation (CR) employ specialized instruments to enhance precision and reproducibility, often building on preparatory manual guidance to eliminate subjective variability. These tools provide objective measurements and tracings of mandibular movements, facilitating accurate capture of the condyles in their superior-anterior-most position within the glenoid fossae.^[16] The leaf gauge, also known as a shim stock or leaf gauge device, consists of a tapered stack of thin metallic or plastic leaves, typically ranging from 0.1 mm to 6 mm in thickness, inserted between the posterior teeth to load the temporomandibular joints (TMJs) and guide the mandible into CR. By progressively adding or removing leaves until the first contact with the opposing dentition is achieved, the device deprograms the lateral pterygoid muscles and identifies the initial occlusal contact point, allowing for a verifiable interocclusal record. This method is particularly valued for its simplicity and repeatability in both diagnostic and restorative procedures.^[17]^[16]^[18] The Gothic arch tracer, or needle-point tracer, utilizes a central bearing device attached to the maxillary and mandibular arches to generate an intraoral tracing of mandibular border movements on a horizontal plane. As the patient performs protrusive and lateral excursions, a stylus creates a V-shaped or arrowhead pattern, with the apex of the arc representing the repeatable CR position due to minimal lateral pterygoid influence at that point. This technique is effective for both dentate and edentulous patients, offering a graphical record that confirms the retruded contact position.^[19]^[20]^[21] Articulators and facebows work in tandem to transfer the recorded CR from the patient to diagnostic models, simulating joint dynamics for verification and treatment planning. A facebow captures the spatial relationship between the maxillary arch and the TMJ hinge axis, mounting the cast on an articulator that adjusts to replicate condylar positioning; a CR interocclusal record then aligns the mandibular cast, minimizing errors in hinge axis transfer (typically under 0.22 mm discrepancy). This setup enables precise occlusal analysis and adjustment on semi-adjustable or fully adjustable articulators.^[22]^[23]^[24]

Digital Approaches

Recent advancements incorporate digital technologies for recording centric relation, offering enhanced precision through non-invasive imaging and analysis, particularly in prosthodontics and restorative dentistry as of 2025.^[25] Intraoral scanners enable digital capture of centric relation by scanning the maxillomandibular relationship after conventional deprogramming, such as with a leaf gauge, to create virtual interocclusal records. This method reduces material use and allows immediate verification on virtual articulators, with studies showing accuracy comparable to analog techniques (deviations under 0.2 mm).^[26] Digital mandibular motion analyzers, like ultrasound-based or optical tracking systems, record real-time condylar positions during guided movements, quantifying deviations from centric relation with high reproducibility (e.g., 0.1–0.3 mm in asymptomatic patients). These devices integrate with CAD/CAM workflows for patient-specific adjustments.^[27] 3D-printed trifunctional appliances combine deprogramming, tracing, and registration functions, fabricated from intraoral scans to guide the mandible into centric relation digitally. Such tools streamline workflows and improve outcomes in complex rehabilitations.^[28]

History and Controversies

Historical Development

The concept of centric relation emerged in the early 20th century amid efforts to establish a reproducible mandibular position for prosthodontic restorations, particularly to enhance denture stability by aligning the mandible with the posterior border of its movement. G.S. Monson contributed to this foundation in his 1918 publication, describing occlusion principles that emphasized the posterior positioning of the condyles to achieve balanced contacts and prevent instability in crown and bridgework as well as complete dentures.^[1] This approach reflected the era's focus on geometric theories of mandibular motion, where centric relation was viewed as a stable reference point derived from the terminal hinge axis. By the mid-20th century, advancing research on temporomandibular joint (TMJ) anatomy prompted refinements in the concept, shifting emphasis from a purely mechanical "retruded" posterior position toward one incorporating physiologic factors for better clinical reproducibility. T.E.J. Shanahan, in 1956, advocated for recording centric relation at the physiologic vertical dimension through swallowing-guided techniques, positioning the condyles in an unstrained state within the glenoid fossae—laying groundwork for later anterosuperior interpretations influenced by TMJ studies on condylar seating.^[29] This evolution addressed earlier limitations of rigid posterior guidance, promoting a more dynamic understanding tied to natural mandibular function. Standardization efforts culminated with the Academy of Prosthodontics' first edition of the Glossary of Prosthodontic Terms (GPT-1) in 1956, defining centric relation as "the most retruded relation of the mandible to the maxilla when the condyles are in the most posterior unstrained position in the glenoid fossa."^[2] Subsequent revisions, such as GPT-2 in 1960, retained the posterior emphasis while acknowledging multiple interpretations to accommodate clinical variability, and GPT-3 in 1968 further stressed its physiologic reproducibility around the terminal hinge axis.^[2] These editions marked a pivotal consolidation, prioritizing repeatable border positions for prosthodontic accuracy over earlier theoretical models. Later developments reflected advances in TMJ imaging, such as arthrography and MRI. In GPT-5 (1987), the definition shifted to an anterior-superior position of the condyles against the posterior slopes of the articular eminences, emphasizing the role of the articular disc and superior joint space.^[2] This change departed from the posterior focus of prior editions. Subsequent revisions, including GPT-9 (2017), maintained this anterosuperior positioning while clarifying its independence from tooth contact and clinical reproducibility.^[1]

Ongoing Debates and Modern Perspectives

One ongoing debate in prosthodontics centers on the reproducibility of centric relation (CR) as a reliable reference position, with studies demonstrating significant variability that challenges its universality. In completely edentulous patients, for instance, reproducibility was achieved in only 70% of cases, with mean deviations from the initial CR point increasing from 0.46 mm at 6 months to 1.13 mm at 24 months, attributed to factors like age, ridge resorption, and vertical dimension changes.^[30] Similar variability, ranging from 0.5 to 1 mm across recording methods, has been observed in dentate subjects, influenced by operator technique, patient morphology, and TMJ health, leading critics to argue that CR does not consistently represent a stable, repeatable mandibular position for all clinical scenarios.^[31] Alternative perspectives advocate shifting away from traditional CR toward more physiologically driven approaches, such as muscle-centric positions or patient-specific maximum intercuspation position (MIP). Proponents of neuromuscular dentistry emphasize "myocentric" jaw relations, where muscle relaxation and electromyographic guidance determine condylar seating over manual manipulation, claiming superior stability in functional occlusion.^[32] Some researchers propose abandoning the CR term entirely due to its inconsistent definitions and lack of anatomical validation, recommending instead a "maxillo-mandibular utility position" tailored to treatment needs or relying on MIP as the default in healthy patients, where over 90% exhibit a natural CR-MIP discrepancy without pathology.^[33] In modern consensus, the American College of Prosthodontists endorses CR as a foundational reference for complex cases like complete edentulism or extensive rehabilitations, particularly for accurate maxillomandibular records and occlusal schemes, while allowing flexibility through patient-specific adaptations and digital alternatives to traditional methods.^[34] This pragmatic approach integrates advanced imaging, such as cone-beam computed tomography (CBCT), to verify condylar positions in CR against MIP, enabling precise evaluation of discrepancies with sub-millimeter accuracy and reducing reliance on subjective recordings.^[15]

References

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