TEMPOROMANDIBULAR JOINT l OCCLUSION

SECTION EDITOR
GEORGE A. ZARB

Centric relation as the treatment position

Dennis B. Gilboe, D.D.S., M.S.*
University of Alberta, Faculty of Dentistry, Edmonton, Alta., Canada

C entric relation is a classical reference and treat-

ment position. It has been variously described as the
rearmost, uppermost, midmost,’ completely retruded,’
most posterior position from which lateral movements
can be made,3 posterior functional range,’ and the most
superior position the condyles can assume in the
glenoid fossa. Centric relation has been defined in SO
many different ways that its credibility for the clinician
is questionable.
Centric relation invariably is defined as a condyle-
fossa spatial relationship, with no specifications of the
position and role of the intra-articular tissue. These
concepts likely originated through observation of dry
specimens and unfortunately have been perpetuated by
radiographic two-dimensional projections of the osse-
ous components.6-g
The objective of this article is an analysis of the
morphology and functional matrix of activity of the
mandibular condyle-intra-articular tissue-articular
eminence mechanism, which is fundamental to a clar-
ification of centric relation as a clinically relevant
location.
FORM AND FUNCTION OF
TEMPOROMANDIBULAR JOINT
STRUCTURES
Normal functional movement of the temporoman-
dibular joint entails apposition of the articular surfaces
of the condyle and eminence, with consideration of the
anatomy and position of the interposed intra-articular
tissue. A description of centric relation must include the
functional relationship of the intra-articular tissue to
be clinically significant.
This soft tissue structure has four definable zones:
the thinner central bearing area and the thicker anteri-
or and posterior bands (the “disk”), and the bilaminar
zone (Fig. 1).9 Anatomic dissections indicate that the
central bearing area of the intra-articular tissue
Presented before the Pacific Coast Society of Prosthodontists, Jasper,
Alta., Canada.
*Professor and Chairman, Division of Fixed Prosthodontics.
Fig. 1. Anatomic zones of disk.
remains interposed between the condylar articular
surface and the articular eminence during simulated
joint movements.‘0-‘2
Arthrotomography of temporomandibular joint
movement confirms that these proposed mechanisms of
normal joint movement are correct.“-‘6 Failure of the
central bearing area of the intra-articular tissue to
remain in apposition to the articular surface of the
condyle is associated with joint abnormalities, includ-
ing displacement (clicking and locking) and perforation
of the disk.
The central bearing area is composed of densely
woven collagen fibrils having no vascularity or inner-
vation, which indicates that this zone is adapted to
accept pressure.‘7-20 Evidence that the condyle is a
stress-bearing structure,2i,22 and the continuous posi-
tioning of the disk on its articular surface throughout
normal movements as revealed by arthrotomography,
suggests that the central bearing area must assume
pressure during function. It may be a primary role of
this zone, as the thickened posterior band possesses
vascularity and innervation.‘O
Because the articular eminence is an inclined plane,
the condyle-disk assembly must be stabilized on this
slope by muscular activity unless it is in a position of
biomechanical equilibrium. The posterior limit of

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Fig. 2. Wedging of posterior band between distal
surface of condyle and roof of fossa.
Fig. 3. Bimanual manipulation technique directs a
superoanterior force to condyles.
movement of the condyle on the eminence has been
attributed to wedging of the thickened posterior band of
the disk between the distal surface of the condyle and
the roof of the articular fossa (Fig. 2$.12The innervated
posterior band possibly protects, by sensory feedback,
the thin roof of the articular fossa from heavy pressure
and p&ides a biomechanically stable relaGonship.l” It
appears that any position posterior to this limit cannot
be functional, as the condylar articular surface cannot
engage the central bearing area of the disk and the
eminence; nor can the position be biomechanically
stable. Thus, the posterior functional limit of condylar
movement is defined specifically by the intra-articular
tissue and the articular eminence, not by the oversim-
plified concept of a condyle-fossa spatial relationship.
686
GILBOE
Fig. 4. Bimanual manipulation technique tends to
wedge a slightly displaced disk to correct position.
These factors indicate that centric relation, if it is to be
a functional position, should be considered for redefini-
tion as “the most superior position of the mandibular
condyles with the central bearing area of the disk in
contact with the articular surface of the condyle and the
articular eminence.” This position is consistent with
the load-bearing capacity of the posterior slope of the
articular eminence,23,24the adaptation of the intermedi-
ate zone of the disk for transmission of pressure, and
the biomechanical stability of the joint resulting from
the shape of its components.
CLINICAL CONSIDERATIONS
Three fundamental approaches to positioning the
mandible in centric relation have been advocated:
chin-point guidance,25 bimanual manipulation,26 and
anterior deprogramming devices.27z28All techniques
either presuppose or ignore two critical specifications:
(1) disk location and (2) the resistance of capsular
ligaments to posterior displacement.
Disk location
Centric relation, as redefined, may not be possible
because of anterior dislocation of the disk. If the
malposition is minimal, it may be possible to seat the
disk in its desired position by manipulating the mandi-
ble in an appropriate way.
Dawson’s26 bimanual manipulation technique posi-
tions the mandible posteriorly while simultaneously
directing force superoanteriorly on the condyles (Fig.
3). Pressure exerted through the condylar articular
surface on the slightly displaced posterior band tends to
wedge the disk to its correct position (Fig. 4), which is
the central bearing area. A similar effect is possible
NOVEMBER 1983 VOLUME 50 NUMBER 5
CENTRIC RELATION

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Fig. 5. Anterior deprogramming devices result in a
similar application of force to bimanual manipulation
because of vectors of action of major elevator
muscles.
Fig. 6. Chin-point guidance is unreliable in reestab-
lishing correct position of a displaced disk since an
essentially posterior force is applied.

with an anterior deprogramming device. Its anterior

inclined plane tends to position the mandible posterior-
ly, while the major elevator muscles simultaneously
direct a superoanterior force to the condyles to position
them superiorly on the eminence (Fig. 5). Guichet’sz5
chin-point guidance cannot be relied on to reestablish
the desired relationship of the malpositioned disk
because of the essentially posterior vector of force
applied (Fig. 6).

Capsular ligaments
The fibers of the temporomandibular ligament are
oriented in appropriate directions to limit posterior
movement of the mandible.29 A posterior force tends to
pivot the condyle superoanreriorly because of the
restriction exerted by this ligament (Fig. 7). Anatomi-
cally, the capsular ligament by its attachments to the
disk could be expected to maintain the central bearing
area of the disk in contact with the condyle. It is Fig. 7. Posterior force rotates condyle superoposte-
apparent that if these ligaments are stretched and/or riorly.
damaged, their capacity to resist undesirable posterior
positionings of the mandible is impaired. Ruptures or
tears of the capsular ligament have been observed with material.” The posterior attachment may be stretched
arthrography in patients with temporomandibular or torn and allow the condyle to articulate with the
joint dysfunction.‘3z 14,16It appears that these perfora- richly innervated bilaminar zone,14which is evidently
tions are produced iatrogenically,30 as none were painful. It becomes apparent that for normal function,
observed in a study of a normal control group of the central bearing area of the disk must remain in
patients. contact with the articular surface of the condyle
With an anteriorly displaced disk, the condylar throughout the range of mandibular movement.
articular surface bears on the posterior band of the When internal derangements exist (indicated by
intra-articular tissue. Tears in the posterior band have clicking, locking, or pain in the temporomandibular
been observed with arthrography14 and in autopsy joint), centric relation as defined earlier in this article is

THE JOURNAL OF PROSTHETIC DENTISTRY 687


generally unattainable because of mallsition of the
intra-articular tissue. None of the mandible manipula-
tion techniques can be depended on to achieve the
defined condyle-disk-eminence relationship.
DISCUSSION
Radiographic examinations, particularly arthro-
grams, have been instrumental in providing informa-
tion that clarifies the understanding of normal function
of the temporomandibular joint. Tomographic and
arthrographic examination provides diagnostic corrob-
oration of internal derangements subsequent to a
clinical differential diagnosis.
Laminagraphic studies on asymptomatic patients of
condylar position when recording centric relation
demonstrate considerable variation in the width of the
space between the condyle and the fossa. This may be
explained by anatomic variations in the shape of the
condyle and the contours and thickness of the intra-
articular tissue. The use of radiographs, either lateral
projections or tomograms, to establish a condylar
treatment position should therefore be discouraged
because of their apparent unreliability.
Placement of the mandible in its most posterior
position may result in a reproducible location. Howev-
er, the mere reproducibility of a position cannot be
construed as being either desirable or functional. When
internal derangements of the temporomandibular joint
exist, the most posterior position is probably patholog-
ic, as revealed by arthrotomographic studies.
A clinical evaluation and history are critical consid-
erations in assessment of structural and functional
integrity of the joint: (1) clicking and locking, (2)
limitation of movement, or (3) pain in the temporo-
mandibular joint when attempting to manipulate the
mandible to centric relation are indicators that internal
derangements should be suspected.
It is possible to retrude the mandible sufficiently
enough so that the condyle-disk assembly is no longer
in contact with the eminence. In essence,the condyle is
being displaced posteriorly into the fossa space.33-35
This relationship may be inadvertently established in
restorations or prostheses if a concept of posterior
reproducibility is the sole criterion of a desirable
treatment position. The result is iatrogenic creation of
an internal temporomandibular derangement.
Centric relation requires structural and functional
harmony of osseous structures, the intra-articular tis-
sue, and capsular ligaments if it is to be a functional
position. If these specifications cannot be fulfilled, the
patient does not have a centric relation.
Initial therapy under these circumstances should be
688
GILBOE
directed toward reestablishing centric relation, as rede-
fined in this article, with the use of an appropriately
designed bite plane or condylar repositioning appli-
ance.36 Restorative and prosthetic services should be
postponed until centric relation is established and
confirmed by the absence of symptoms and signs during
a clinical trial period. Otherwise, the entire mechanism
is unstable, and the results of occlusal treatment will be
unpredictable and unstable.
SUMMARY
Centric relation should be considered as “the most
superior position of the mandibular condyles with the
central bearing area of the disk in contact with the
articular surfaces of the mandibular condyles and the
articular eminences.” This relationship is justifiable on
analysis of the morphology and function of temporo-
mandibular joint structures.
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CENTRIC RELATION

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