Journal of Oral Rehabilitation 2002 29; 458466

Accuracy of check-bite registration and centric condylar position

K . - H . U T Z * , F . M U L L E R , W . L U C K E R A T H * , E . F U & B . K O E C K *

*Department of Prosthetic

Dentistry, University of Bonn, Bonn, Germany, Department of Prosthetic Dentistry, University of Mainz, Mainz, Germany and Institute for Applied Mathematics, University of Bonn, Bonn, Germany

SUMMARY

In a dentate subject a jaw relation can either be determined in maximum intercuspation and is as such given by the occlusal morphology, or the mandibular position can be allocated according to the centric position of the condyles. For comprehensive restorative treatment or analytic measures of the occlusion it is important to record the centric condylar position. Various registration methods have been described in the literature, but there is no consensus on which is the best. The aim of the present study was therefore to assess the accuracy of various registration methods and evaluate a possible inuence of the used materials. Four dentists were involved in the clinical part of the study, another was responsible for the measurements. Impressions were taken from 81 fully dentate volunteers. The casts were mounted by face-bow transfer and central-bearing-point (CBP) registration into Dentatus articulators. Subsequently the centric condylar position was determined with six different methods and materials, respectively. Each method was reproduced twice so that a total of 18 registrations was performed per patient. The mandibular positions which resulted from the individual registra-

tions were then repeatedly compared in the condylar area using a computer supported specially modied measuring articulator. The accuracy was found best for the unrened wax wafer registration (x=033 mm) and with an average of 044 mm worst when using acrylic wafers. The CBP and frontal jig methods as well as tin-foil and rened wax wafers showed an accuracy in-between these boundaries. The biggest measured mandibular displacement between any two registrations were considerably 20 mm. However, the described differences in accuracy between the various methods and materials proved statistically not signicant. All investigated jaw registrations showed an accuracy of about 20 times the tactile ne sensibility of natural teeth which has to be taken into account when inserting xed prosthetic restorations in centric condylar position. Despite meticulous clinical and technical procedures small occlusal adjustments are therefore almost unavoidable. KEYWORDS: restorative dentistry, jaw relation, centric condylar position, check-bite, central-bearingpoint registration

Introduction
In restorative dentistry check-bite registrations with interocclusal clearance are used to determine the centric condylar position into an articulator. They are distinctively different from registrations which lead to maximum intercuspation of the teeth and thus have a different indication. The centric condylar position not only plays an important role in the diagnosis and
2002 Blackwell Science Ltd

treatment of the myofacial pain dysfunction syndrome, it is also essential for a comprehensive restorative treatment. Under moderate manipulation of the operator the condyles are guided in the upmost, retral and concentric position of the condylar fossa so that the lower jaw can rotate open without any transversal or sagittal shift. This position thus allows minor adjustments of the vertical dimension to be performed in the articulator, without changing the occlusion of the patient.

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The clinical indication of this man-made position of the lower jaw has for decades been the subject of a still ongoing controversial discussion. A variety of methods to determine the centric condylar position came into fashion over the course of time (Academy of Denture Prosthetics, 1968, 1977, 1987; Arbeitsgemeinschaft fur Funktionsdiagnostik, 1992; Academy of Prosthodontics, 1999). Likewise, the question as to what is the best material is still open. In contrast consent exists that any antagonistic tooth contact must be avoided during the registration, so that the mandibular position is solely determined by the joint. Given a full dentition interocclusal clearance can only be achieved by increasing the vertical dimension. However necessary for the mentioned reasons, the interocclusal separation should still be kept as small as possible, because eventually the upper part of the articulator has to be closed down into occlusion. This rotation only reects the patients real movement when the hinge axis was determined individually and a face-bow transfer was used. When using arbitrary hinge axes the inevitable sagittal shift increases proportional to the interocclusal distance. impression material (Panaseal*). The impressions were poured twice from super stone plaster (Fuji Rock). The rst cast was used for the experiments, the second served to manufacture pre-shaped acrylic wafers and acrylic plates for the central-bearing-point (CBP) registration (Condylator Set No. 110). In a second session registrations were performed by four different operators (L: n 19; N: n 18; S: n 19; U: n 25). The subjects were seated upright in a dental chair with the Camper plane ~ 30 inclined to the oor. The individual hinge axis was located by means of the SAM Axiograph No2 and marked on the skin for a face-bow transfer (Dentatus AEK). The upper cast was then mounted into newly adjusted Dentatus ARL articulators with an Adesso** Magnet-QuickSplit-System, which allowed an accurate transfer of the mounted casts to the specially modied measuring articulator (Bernard et al., 1994). The CBP-registrations were always performed rst, subsequent registrations followed in a random order. Each method was carried out three times. The wafers were pre-shaped using the Lauritzen-grip (Lauritzen & Wolford, 1961) which involves manual guidance of the chin with a moderate retral force of ~ 25 N combined with bilateral anterior and cranial support of the mandible with the ngers. For the nal registration the pre-shaped impressions were rened using the Dawson-grip (Long, 1970; Dawson, 1979). Only the CBP-registration and the frontal-jig method did not involve any manipulation through the operator during setting of the material. Any deep impressions were cut back and the registrations were checked for an accurate t on the casts.

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Aim
The aim of the present study was to investigate the following questions: 1. How accurate can the centric condylar position be recorded? 2. Do different registration methods and materials inuence the accuracy?

Materials and methods

Subjects Thirty-six female and 45 male volunteers with an average age of 268 years (1855, 62) were recruited from the students and staff of the Dental School of the University of Bonn. Prerequisites for participation were a full dentition and no signs of temporomandibular dysfunction. The average number of llings in the side teeth was 74 59 (from 0 to 26); 11 subjects had no llings at all.

Central-bearing-point registration For the CBP-registrations a gothic arch was recorded under moderate mandibular guidance. The interocclusal clearance during only initial mandibular movements was checked with occlusal indicator foil. A pierced plastic rondel was glued on the tip of the gothic arch to hold the mandible in centric condylar position. This

Experimental protocol In the rst session impressions were taken from the upper and lower jaw using a monophasic A-Silicone
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*Kettenbach, Eschenburg-Eibelshausen, Germany. GC Germany GmbH, Munchen, Germany. Condylator Service, Zurich, Switzerland. SAM Prazisionstechnik GmbH, Munchen, Germany. AB Dentatus, Hagersten, Sweden. **Malzer-Dental, Steinhude, Germany.

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Fig. 1. The various investigated registration methods displayed. (a) From left to right: CBP-registration, tin-foil wafer, acrylic wafer, frontal jig registration, plain wax wafer, and rened wax wafer. (b) From left to right: CBP-registration, tin-foil wafer, acrylic wafer, frontal jig registration, plain wax wafer, and rened wax wafer.

posture was subsequently xed with full-arch interocclusal impression plaster (Kerr Snow White Plaster No. 2) (Fig. 1). The plaster keys were trimmed and used to mount the lower casts. Two more CBP-registrations were produced in the same manner. For neuromuscular relaxation after the CBP-registrations nished the subjects were asked to tap their teeth and thus produce an adduction eld.

Tin-foil wafer registration A further registration method used tin-foils of 09 mm thickness (Dentaurum) which were shaped slightly exceeding the dental arch and roughened with a bur in the area of the occlusal surfaces. Pre-shaping was achieved by bending the outer rim up whilst the patient bit in occlusion. Then tray-glue and a small amount of

Kerr GmbH, Karlsruhe, Germany.

Dentaurum, Pforzheim, Germany.

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zinc-oxide-eugenol paste (Bosworth Superbite Paste) were layered on the topside of the tin-foil which was then adapted to the upper teeth until the paste had set. The centric condylar position was nally registered using Bite Compound (GC-Dental) on the lower side of the wafer (Fig. 1). The other three were rened with zinc-oxide paste (Super Bite) in the area of the upper cusps. The registration of the centric condylar position was then nally performed with bilateral stops of ame-heated Aluminium wax (Alminax) in the canine and molar area of the bottom side of the wafer (Fig. 1).

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Acrylic wafer registration The acrylic wafers were manufactured from lightcuring Dentsply Triad. Intraorally they were adapted to the upper teeth with a thin, gel-like acrylic (TriadGel) which was light-cured from the bottom and with the mouth open through the acrylic wafer. Small strips of non-cured Triad material were then applied to the bottom side of the wafer to register the centric condylar position under moderate manual guidance. Light-curing took place extraorally in a Triad light-oven. That way the wafer consisted only from one material: lightcuring acrylic (Fig. 1).

Measurements The mandibular positions achieved with the various registrations were analysed by a fth dentist who was not involved in the clinical procedures. The measurements took place in a separate room and were carried out immediately following the clinical session. Upper and lower casts were transferred from the conventional Dentatus ARL-articulators with the Adesso**-QuickSplit-System into one which was specially modied for the experiments. Similar to the Kondymeter (Gausch & Kulmer, 1978) and Posselts Gnatho-Thesiometer (Posselt, 1957) had the upper part of the articulator been detached so that its position was solely determined by the registration materials which were interposed between the upper and lower dental arches. All readings were taken under a load of 10 N (Fig. 2). The bottom part of the measuring device was equipped in the condylar area with three gauges on each side (Mitutoyo IDC 1012 B) so that readings of the mandibular position could be taken electronically with a reproducibility of 001 mm. Data were recorded, stored and off-line analysed with a specially developed Software. Measurements were taken from all 18 registrations and each measurement was immediately repeated after re-assemblation of the cast and registration complex.

Frontal-jig registration A jig was formed from thermoplastic compound (Kerr) and placed on the incisors in a way that held the lower jaw in centric condylar position. The jig was moulded just like a leaf-gauge until the interocclusal leeway was minimized (Long, 1973; Woelfel, 1986). That way the mandibular posture was stabilized in anteriorposterior direction but the occlusal surfaces of the side teeth were still minimally out of contact. A eece KKD-Tray*** was therefore loaded with GC Bite Compound, heated for 20 s at 50 C and then placed between the opposing dental arches. The registration was let cool for 3 min whilst the frontal-jig was in place and then removed from the mouth (Fig. 1).

Statistical analysis First data from double repeated measurement were averaged. The differences between mandibular position which were obtained with three independent registrations were analysed (reg.1 ) reg.2; reg.2 ) reg.3; reg.1 ) reg.3). The accuracy of the method is expressed by averaging these mandibular shifts over all subjects. The spacial mandibular displacement between any two p registrations was calculated as d a2 b2 c 2 with a, b and c representing the three room directions. The

Rened and unrened wax wafer registrations For the wax wafer registrations extra-hard Beauty Pink was used in double layers. The wax wafers were tempered at 50 thermal C in a water bath before the centric condylar position was determined. A total of six wafers was produced, three of which were left plain.

Dentsply DeTrey GmbH, Dreieich, Germany. ***Kentzler Kaschner Dental GmbH, Ellwangen, Germany. Ubert GmbH&Co.KG, Lohfelden, Germany. 2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 458466

Associated Dental Products Ltd, Purton, Swindon, Wiltshire, UK. Mitutoyo, Neuss, Germany.

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accuracy seemed best in transversal direction, but this was not signicant (Table 2). The biggest measured mandibular displacement between any two registrations was a striking 213 mm. However, none of the described differences in accuracy between the various methods and materials proved statistically signicant, nor did the patients gender or the operator have an effect on the accuracy of the investigated registration methods (n.s.).

Discussion
Critique of method It is in the nature of any clinical study that a variety of parameters bias the results. Impressions and pouring might have led to inaccuracies of the casts. Biological parameters and the experience and temperament of the operator exert an inuence on the differences between the mandibular position gained by sole repetition of the registration procedure. But even with these inevitable inuences in mind the results stand on a sound basis: the accuracies were calculated from three independent registrations and each reading was repeated after re-assembling the casts and registration materials. Another critique of the method could be the substantial interocclusal separation during registration which was necessary to achieve interocclusal clearance (Table 3). However, the accuracies were calculated from readings with the registration material in place, so basically at similar interocclusal separation. The reported accuracies do not apply when the upper part of the articulator is closed down in occlusion. In this clinical situation the face-bow transfer plays an additional role. When interpreting the results it should further be born in mind that the three registrations were not checked for identity with a split-cast before the readings were taken. That way odd registrations could have been revealed as outliers and re-done before they were included in the study.

Fig. 2. The non-arcon measuring articulator is in both condylar areas equipped with three electronic detectors, each measuring one room direction. Readings were taken under a load of 10 N.

statistical analysis was performed with the software package SPSS. Mandibular shifts between any two  registrations of more than x 4 s.d. were considered outliers and excluded from further analysis. A 5% level of probability was requested for statistical signicance. Differences between methods, operators and gender of the subjects were tested by means of the Wilcoxon U-test and the KruskalWallis H-test, respectively (Sachs, 1991; Toutenburg et al., 1991).

Results
The accuracy was found best for the unrened wax wafer registration ( 033 mm) and with an average of x 044 mm worst when using acrylic wafers. The CBP and frontal jig methods as well as tin-foil and rened wax wafers showed an accuracy in-between these boundaries (Table 1, Fig. 3). Except for the CBP-registration the

Interpretation of data Four different operators were involved in the clinical procedures. Each of them carried out a similar number of experiments. Despite the sufcient sample size a paired comparison between operators remains precarious because they examined different subjects. Possible differences were therefore studied with an unpaired
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Table 1. Accuracy of the different registration types. Differences are calculated as spacial vector (left and right side) Differences of the mandibular position in the three room directions Registration type (n 81 subjects and 233237 measurements) Central-bearing-point (with plaster key) Frontal jig (with bite compound) Tin-foil wafer Acrylic wafer Wax wafer Rened wax wafer Median (mm) 034 034 032 034 027 028 Mean (mm) 043 043 040 044 033 034 s.d. (mm) 018 012 010 013 008 010 Maximum (mm) 213 177 169 216 137 147 Not analysed outliers (n) 3 2 3 2 4 4

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Fig. 3. The accuracy of the investigated registration methods depicted as Box and Whisker plot.

Table 2. Accuracy of the different registration methods in the three room-directions (mean and s.d.) Differences of the mandibular position in the three room directions (mm) Registration type (n 81 subjects and 233237 measurements) Central-bearing-point (with plaster key) Frontal jig (with bite compound) Tin-foil wafer Acrylic wafer Wax wafer Rened wax wafer Right Sagittal 020 024 021 025 016 020 017 019 020 022 016 019 Vertical 023 030 027 030 020 021 020 028 025 024 020 020 Transversal 018 013 011 013 011 011 018 012 010 012 008 009 Left Sagittal 022 024 023 022 018 017 023 022 020 022 015 014 Vertical 027 026 027 030 022 021 027 022 024 029 020 020 Transversal 019 012 011 013 011 011 018 011 010 013 008 010

(mm)

test-method (KruskalWallis H-test) but no signicant inuence of the operator was found. Previous reports in the literature are controversial (Piehslinger et al., 1993; Tuppy et al., 1994, Lentner et al., 1997) and did not always validate the differences between operators in
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relation to the accuracy of the method. The present results conrm own previous ndings (Utz et al., 1990) and are furthermore supported by Piehslinger et al. (1993) and Tuppy et al. (1994). In a clinical context it is favourable when a treatment method is insensitive to the

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Table 3. Incisal separation during the registration Registration type (n 80 subjects) Central-bearing-point (with plaster key) Frontal jig (with bite compound) Tin-foil wafer Acrylic wafer Wax wafer Rened wax wafer Median (mm) 38 30 39 55 50 64 Mean (mm) 37 30 40 54 47 62 s.d. (mm) 12 10 13 14 14 11 Minimum (mm) 2 2 2 4 2 5 Maximum (mm) 7 7 8 8 7 9

operators experience, mood and temperament because it enhances the consistency of the quality standard. Both, the mean and median values of the accuracy were not signicantly different between the investigated registration methods nor was the maximum shift between any two registrations (Table 1). These results were unexpected, because a better accuracy had been anticipated when using the Dawson grip (tin-foil, acrylic wafer and both wax wafer registrations). The clear independence from the type of manual guidance indicates a subordinated importance of the operator and emphasizes the role of the ligaments for the reproducibility of the centric condylar position. The subjects average age of 26 6 years and the health of their joints brings forward the question whether a similar accuracy would have been achieved had the subjects been elderly or suffering from temporomandibular dysfunction. For example in denture wearers of an average age of 67 9 years the accuracy of the centric condylar position registration was found between 05 and 07 mm and was thus reduced in comparison with the fully dentate sample of this study (Utz et al., 1995). However, in this matter the age-related looseness of the joints was most likely of inferior importance in com-

parison with the mobility of the dentures on the denture bearing tissues. The accuracy of the different registrations varied between the three room directions: in the sagittal and vertical plane the accuracy was found less good than in transversal direction. Manual guidance of the mandible is therefore least fault-prone in the anteriorposterior direction. These ndings conrm reports from Shafagh et al. (1975) and Staehle (1983) but contradict the ndings of Alexander et al. (1993) as well as Simon and Nicholls (1980). A possible explanation for the good transversal accuracy might be that all operators were rmly instructed to hold the lower arm concentric during registration. The comparison of the present results with data from the literature is difcult because of different methods and statistical analyses were employed (Sauer, 1969; Helkimo et al., 1973; Shafagh et al., 1975; Horn & Vetter, 1976; Jahnig, 1979; Shafagh & Amirloo, 1979; Hellsing et al., 1983; Staehle, 1983; Balthazar et al., 1984; Hellsing & McWilliam, 1985; Ohlrogge et al., 1990; Alexander et al., 1993; Piehslinger et al., 1993; Wood & Elliott, 1994; Ahlers & Edinger, 1995; Lentner et al., 1997) (see also Table 4).

Table 4. Literature review on the accuracy of the centric condylar position in the individual room directions (measured in the condylar area) Author Sauer (1969) Utz et al. (1992) n 12 46 Remarks Ten registrations, hinge axis of articulator xed, central-bearing-point (CBP) Nine registrations each, different materials, on-site recording, hinge axis of articulator detached, CBP Five registrations each, hinge axis of articulator detached (Varicheck), wax wafers Nine registrations each, at different sessions, hinge axis of articulator detached (MPI), registrations with frontal jig Results (mm) Sagittal: 025 025 Sagittal: 016 015 Vertical: 016 017 Transversal: 013 011 Sagittal: 061 Sagittal: 004 007 Vertical: 005 022 Transversal: 015 007

Staehle (1983) Alexander et al. (1993)

3 28

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The present results can be compared with own previous studies on CBP-registrations where the accuracy of the CBP-method was found with 029 022 mm (spacial vector) slightly better than in the present study (Utz et al., 1992). This slightly higher precision might have been caused by rejecting outliers at chair-side using a sort of electronic split-cast. However, the range of the accuracy was still similar to this study. The accuracy of any registration method evaluated under clinical conditions is inevitably worse than in a bench test where readings are taken from the casts on which the registrations were produced (Muller et al., 1990a,b,c). The present results indicate that the inuence of the different registration materials is smaller than the clinical reproducibility of the method. This coincides with results from Ahlers and Edinger (1995). The accuracy seems therefore limited by the soft and bony structures of the orofacial system but neither the material nor the method employed. Consequently even in healthy fully dentate subjects it is impossible to determine the centric condylar position with absolute precision. Each registration leads to just one out of a eld of possible positions for the condyle (Long, 1970; Helkimo et al., 1973; Lundeen, 1974; Simon & Nicholls, 1980; Teo & Wise, 1981; Utz et al., 1992). If the centric condylar position is used for a full occlusal restoration the patient has to adapt to this man-made or concept-position. All investigated jaw registrations showed an accuracy of about 20 times the tactile sensibility of natural teeth (Utz, 1982, 1986a,b) which has to be taken into account when inserting prosthetic restorations in centric condylar position. Despite meticulous clinical and technical procedures small occlusal adjustments are therefore almost unavoidable.

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Acknowledgments
Dr Wolfgang Noethlichs, Dr Peter Schwarting and Dr Ralf Buttner were involved in the clinical procedures. The software for data collection was written by Dipl.Phys. Manfred Gruner, the box-plots were drawn by Dr Axel Malchau. Ms Hannelore Hanke was a precious help with the literature search. Finally we would like to gratefully acknowledge Dr James P. Newton for correcting our English. This study was supported by the German Society of Dentistry and Oral Medicine (DGZMK).

References
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Conclusions
For the registration of the centric condylar position by means of check-bites or CBP there is neither one ideal method nor material. All investigated registration methods provided similar outcomes with an median spacial accuracy of 03 mm. Furthermore not every registration of the centric condylar position is successful, differences of more than 2 mm do occur with all methods. It is therefore crucial to produce several registrations and check the accuracy by means of a split-cast. Also the interocclusal separation should be kept as small as possible when arbitrary hinge axes were used for the face-bow transfer.
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Correspondence: Dr Karl-Heinz Utz, Poliklinik fur Zahnarztliche Prothetik, Welschnonnenstrae 17, 53111 Bonn, Germany. E-mail: Karl-Heinz.utz@ukb.uni-bonn.de

2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 458466