centric relation a historical and contemporary orthodontic perspective

494 JADA, Vol. 137 http://jada.ada.org April 2006
CLINICAL PRACTICE PRACTICAL SCIENCE
Background. Centric relation (CR) has been a controversial subject in
dentistry for more than a century. For at least the past four decades,
issues involving CR have been of interest to orthodontists. The definition
of CR has changed over the past half-century from a retruded, posterior
and, for the most part, superior condyle position to an anterior-superior
condyle position.
Type of Studies Reviewed. The authors addressed the historical
and contemporary orthodontic perspective of CR. The source material for
this review came mainly from literature and searches the lead author
accumulated over the last 30 years. As there is no evidence-based (EB)
model level 3 (systemic) review on the topic of CR, the best evidence on
this subject was gleaned only from a thorough examination and evalu-
ation at EB model level 2 (experience plus best available sample studies).
There was, however, enough high-quality EB model level 2 information
on the topic of CR for the authors to draw conclusions on the basis of a
scientific appraisal of relevant research.
Results. Although the reliability of CR records has been substantiated,
the records’ validity has little to no evidentiary support. In addition,
population-based sample studies and consensus statements from national
conferences support the view that the positions of the temporomandibular
joint (TMJ) condyles in relation to the glenoid fossa or CR position are not
diagnostic of temporomandiblar disorders. There appears to be little to no
benefit of using gnathologic records and articulator-mounted dental casts
to discern discrepancies in maximum intercuspation of the teeth coinci-
dent with TMJ condyles in an anterior-superior CR position in ortho-
dontic patients.
Clinical Implications. The benefit of using gnathologic CR records
and articulators in orthodontics has not been substantiated by scientific
evidence.
Key Words. Centric relation; condyle position; orthodontics.
JADA 2006;137:494-501.
T
he search for the optimal
and preferred types of
static and functional
occlusions has occupied
the minds of dentists for
more than a century. The possible
role of occlusion in the etiology of
temporomandibular disorders
(TMD) also has been the subject of
debate. Much of the occlusion/TMD
debate involves issues surrounding
centric relation (CR), including defi-
nition, recording and measurement,
use of articulators and deprogram-
ming splints, and possible relation-
ship to either stomatognathic health
or disease. The purpose of this
article is to discuss some of the con-
troversies concerning CR, particu-
larly as they relate to orthodontics.
Because there is no evidence-
based (EB) model level 3 (systemic)
review on the topic of CR, the best
evidence on this subject can be
gleaned only from a thorough exami-
nation and evaluation at EB model
level 2 (experience plus best avail-
able sample studies). However,
there is enough high-quality EB
model level 2 information on the
topic of CR to draw several note-
worthy conclusions. Therefore, we
drew conclusions on the basis of a
scientific appraisal of relevant
research based on the EB model
level 2 paradigm. One author
(D.J.R.) accumulated the majority of
the source material for this article
from literature and searches he con-
ducted over 30 years.
A B S T R A C T
Dr. Rinchuse is a clinical professor, Orthodontics and Dentofacial Orthopedics, University of Pittsburgh,
School of Dental Medicine. Address reprint requests to Dr. Rinchuse at 510 Pellis Road, Greensburg,
Pa. 15601, e-mail “bracebrothers@aol.com”.
Dr. Kandasamy is a research fellow in orthodontics, Oral Health Centre, University of Western Aus-
tralia, Perth, and is in orthodontic practice, Perth, Australia.
Centric relation
A historical and contemporary orthodontic perspective
Donald J. Rinchuse, DMD, MS, MDS, PhD;
Sanjivan Kandasamy, BDSc, BScDent, DocClinDen, MOrthRCS
Copyright ©2005 American Dental Association. All rights reserved.

JADA, Vol. 137 http://jada.ada.org April 2006 495
DEFINITIONS OF CENTRIC RELATION
AND CENTRIC OCCLUSION
Dentistry has not arrived at a consensus defini-
tion and concept of CR. In 2004, Christensen1
said
that he and most practitioners “accept the concept
that CR is the most comfortable posterior location
of the mandible when it is bilaterally manipu-
lated gently backward and upward into a retru-
sive position.” However, CR has not been recog-
nized as a posterior, retruded condyle position for
almost 20 years.2
In 2000, Jasinevicius and col-
leagues3
found that faculty and students at seven
dental schools could not agree on a unified defini-
tion of CR.
The definition of CR has evolved over the past
half-century from being a posterior and superior
position of the condyle in relation to
the glenoid fossa to an anterior-
superior position.2,4-7
Before 1987,
CR was considered a retruded
(posterior-superior) condylar posi-
tion. The latest edition of the Glos-
sary of Prosthodontic Terms (GPT)7
defines CR as “a maxillomandibular
relationship in which the condyles
articulate with the thinnest avas-
cular portion of their respective
disks with the complex in the
anterior-superior position against
the slopes of the articular emi-
nences.” This edition of GPT also
includes six historical definitions
of CR.7
CR is a position of the condyles
independent of tooth contact, whereas centric
occlusion (CO) is an interocclusal dental position
of the maxillary teeth relative to the mandibular
teeth.2
Maximum intercuspation (MI) has been
defined as “the complete intercuspation of
opposing teeth independent of condylar position.”6
Although CO and MI have been used synony-
mously in the past, the most recent editions of
GPT6,7
have made a distinction between the two
terms; this has not been well-received within the
profession, most likely owing to resistance to
change.
The common use of the terms “centric relation-
centric occlusion” and “centric relation-maximum
intercuspation” discrepancies, or slides, in some
publications is inaccurate, because CR is not com-
parable with CO or MI. CR is a condyle position,
while CO and MI are interocclusal dental posi-
tions. A previously used term that all editions of
the GPT considered obsolete and referenced along
with CO is “centric relation occlusion” (CRO).
Decades ago, CRO was used by gnathologists to
describe the interocclusal position of the teeth
when the condyles were located in retruded CR.4,5
Past usage of the term “centric relation
occlusion–centric occlusion” discrepancies, or
slides, was semantically appropriate. To avoid
some of the confusion about the term “CR-CO,”
one publication appropriately used the term “CO
condyles” compared with CR.8
Recently, CO-CR
(or CR-CO) and MI-CR (or CR-MI) in which MI is
synonymous with CO, have been use interchange-
ably. Other “centric” terms found in the literature
are intercuspal position (ICP), which is used syn-
onymously with CO, and retruded cuspal position
(RCP), which is a modern reference
to the previously used term CRO.
Hence, some publications have used
the term “RCP-ICP” slides. In our
literature review, common and his-
torical usage of terms will take
precedent over any attempt for total
accuracy.
CENTRIC RELATION AND
ORTHODONTICS
The call for orthodontists to con-
sider the functional aspects of the
dentition dates back to at least the
1930s; several of the prominent pio-
neers were Brodie,9,10
Perry,11,12
Moyer,13
Thompson14-18
and
Ricketts.19,20
In the 1970s, Roth,21-25
a
gnathologic orthodontist, suggested that ortho-
dontists should embrace the principles of
gnathology that had long been held by eminent
prosthodontists and restorative dentists. He rea-
soned that orthodontic treatment is analogous to
doing full-mouth occlusal rehabilitation, with the
difference being that orthodontics did not “cut” or
modify the natural tooth structure. Purveyors of
this view were critical of nongnathologic ortho-
dontists for what they saw as their lack of con-
cern about establishing an “optimal” functional
occlusion in addition to attaining the long-held
traditional goals of static occlusion. A focus of this
gnathologic orthodontic view was to establish a
retruded, posterior-superior “seated” CR position
when the interdigitating occlusion was in CO
(that is, CR-CO). The thinking then was that if a
posterior-superior seated CR position was not an
Centric relation is a
position of the
condyles independent
of tooth contact,
whereas centric
occlusion is an
interocclusal dental
position of the
maxillary teeth
relative to the
mandibular teeth.

established goal of orthodontic treatment,
patients would be prone to develop TMJ symp-
toms.21-25
Furthermore, the attainment of a
retruded, posterior-superior CR position would
mitigate the development of TMD.
Many aspects of this gnathologic orthodontic
view have been abandoned, particularly those
related to the attainment of a retruded, pos-
terior-superior CR position. An impetus for this
shift in thinking was the introduction of more
sophisticated TMJ imaging that demonstrates
TMJ internal derangements and that has led to
the change in the definition of CR from a pos-
terior-superior to an anterior-superior position.
The argument for anterior-superior positioned
condyles was the belief that distally displaced
condyles can cause anterior and medial displace-
ment of the TMJ disks. With this thinking in
mind and relating it to orthodontics, Wyatt26
argued that Class II, division 2 malocclusions;
missing posterior teeth with bite collapse; any
occlusal contacts that may deflect the condyles
posteriorly; and orthodontic procedures such as
the placement of Class II elastics, headgear, chin
cups and certain retainers can cause TMD. How-
ever, this notion and others from this era were
found to be untrue,27-47
particularly the idea that
orthodontic treatment causes TMD.33,37,39,42-46
Changes in the definition and concept of CR
have been determined arbitrarily for the most
part and were not based on science and EB deci-
sion making. Concerning the ideas and notions
of the early orthodontic gnathologists, John-
ston47
wrote, “It could be argued that the pro-
gressive modifications in the definition of CR
have done more to eliminate centric slides than
20 years of grudging acquiescence of the pre-
cepts of gnathology.”
Although contemporary orthodontic gnatholo-
gists believe in attaining an anterior-superior
condyle position at the same time the teeth are in
CR (CR-CO), there is little scientific evidence to
support this view.27
In fact, the evidence supports
a contrary notion. The location and position of the
condyles in the glenoid fossa, irrespective of
where they may be, has not been demonstrated to
be consequential to the presence or absence of
TMD symptoms.48-51
Keim52
said, “The neuromus-
cular school tells us that there is a range of
acceptable positions (centric) … If we clinicians
continue to place emphasis on establishing ‘har-
mony’ between CO and some mythical concept of
CR, we are doing ourselves a disservice.”
CONDYLE POSITION AND CENTRIC SLIDES
The findings in the 1960s that centric slides
caused TMD were based on incorrect information
from descriptive studies that lacked control/
comparison groups. When control/comparison
groups that included subjects without TMD were
added to the studies’ designs, the exact same cen-
tric slides also were observed in these subjects
(comparison group subjects who did not have
TMD). Hence, many of these studies had high
diagnostic sensitivity but poor diagnostic speci-
ficity, which led to false-positive TMD diag-
noses.53,54
Furthermore, intraoral telemetry
studies of the 1960s, in which miniature radio
implants were placed in subjects’ fixed prostheses
and radio frequencies were monitored from out-
side the mouth, found that even though entire
dentitions were reconstructed into retruded CR,
subjects continued to use and function in CO.55-58
In a summary article, McNamara and colleagues59
found TMJ arthropathies associated with centric
slides greater than 4 millimeters; however, they
contended that the slides were the result of the
TMD rather than the cause.
In summary, the preponderance of evidence
available suggests that there is no one ideal posi-
tion of the condyles in the glenoid fossa, but there
is a range of “normal” positions.27,47,53,59
That is,
the three-dimensional position and location of the
condyles in the glenoid fossa are not predictive of
TMD.60,61
Based primarily on dialectical consider-
ations rather than on evidence, anterior to
mid-condyle positions appear to be favored over
posterior, retruded positions.27-32,34-38
RETRUDED CENTRIC RELATION:
THE PAST DATA
In the 1960s and 1970s, CRO was considered to
be the interocclusal position of the teeth when the
mandibular condyles were in retruded CR.4
The
location of retruded CR was calculated from an
interocclusal centric record (that is, CO and CRO)
made from the teeth and not the condyles. Early
studies found that CO usually was 0.1 to 1.8 mm
anterior to CRO, depending on the population
studied and the age of the subjects.62-64
Chin-point
guided records found CO (or CRO) condyles to be
located on average 0.28 to 0.56 mm anterior and
0.26 to 0.85 mm inferior to retruded CR.65,66
Although there was some variation in the find-
ings from intraoral telemetric studies, the prepon-
derance of evidence suggested that, though a few

CRO contacts were found to occur during swal-
lowing, most swallowing and all chewing contacts
occurred in CO.55-58
Furthermore, lateral func-
tional occlusal contacts originate from CO and
not from CRO.55-58
As we previously mentioned,
telemetry research has indicated that even when
patients’ entire dentitions were reconstructed in
retruded CR, they still persisted in using CO.58
In
addition, retruded CR was not believed to be a
natural and physiological condyle position, but
rather an extreme border position.67-71
Interest-
ingly, Jankelson and colleagues72
supported the
view that neither CRO nor CO was physiological
and, therefore, advocated what they
termed the “myocentric” position or
muscle (masticatory) -generated
centric position. They believed that
the myocentric position usually was
located between CRO and CO. On
the other hand, Schuyler 73
and
Mann and Pankey74
advocated a
“long centric” position, in which
occlusal prematurities, or interfer-
ences, were eliminated to and from
CRO and CO.
CENTRIC RECORDS: RETRUDED
CENTRIC RELATION
The early literature on recording CR is related to
retruded CR, not to anterior-superior CR. Fur-
thermore, most CR recordings are dentist-
manipulated, and there are differences in find-
ings from manipulated and unmanipulated CR
recordings.61
Dentist-manipulated CR records
(also known as passive patient CR records) are
considered to be more reliable and less valid than
patient-manipulated records.75-84
One investiga-
tion demonstrated the average range of centric
slide for repeated recordings of retruded CR to be
0.30 mm mediolaterally and 0.27 mm anteropos-
teriorly.85
It appears that recording of retruded
CR in contemporary dentistry makes sense only
in complete denture construction when no inte-
rocclusal reference is possible. Even then, many
prosthodontists use retruded CR only as a guide
so that dentures can be fabricated a millimeter or
so anterior to this position.
ANTERIOR-SUPERIOR CENTRIC RELATION
Logically, one would think that changing the defi-
nition of CR from a posterior-superior to an
anterior-superior position would have eliminated
or reduced the magnitude of centric slides.47
To a
degree, this has proven to be true. Orthodontic
gnathologists recently have found only minor MI-
CR discrepancies for the vertical dimension, but
not the horizontal and transverse dimensions.86
The magnitude of the vertical MI-CR discrepancy
is approximately 1 mm. When the errors in
method, recording and instrumentation are calcu-
lated against this 1 mm figure, the importance of
these findings can be insignificant.81
Nonetheless,
orthodontic gnathologists argue that considera-
tion and measurements of MI-CR slides or dis-
crepancies are still valid.21-25,86-92
Using a Roth “power centric bite registration”
and articulator-mounted models,
Utt and colleagues90
found that CO
condyles were located on average
0.53 mm posterior and 0.72 mm
inferior to anterior-superior CR.
There was, however, a significant
amount of individual variation,
with 39 percent of the CO condyles
positioned anteroinferiorly from
anterior-superior CR.90
Based on
Utt and colleagues90
and Crawford,88
orthodontic gnathologists claim that
anterior-superior CR slides average
0.6 to 0.7 mm horizontally, 0.7 to 0.8 mm verti-
cally and 0.27 to 0.3 mm transversely.89
Recent
investigations comparing gnathologic with non
gnathologic finished orthodontic cases generally
have found articulator-recorded MI-CR differences
of 1 mm or greater in the vertical plane in non
gnathologically treated cases (1.41 mm for the
nongnathologically treated versus 0.41 mm for the
gnathologically treated; difference of 1 mm).87
A CRITICAL APPRAISAL OF THE
CONTEMPORARY ORTHODONTIC
GNATHOLOGIC APPROACH
Today’s gnathologically oriented orthodontists
advocate the use of articulators with dental casts
mounted in anterior-superior CR, with the major
goal of orthodontic treatment being to establish
coincidence of MI-CR.86,93
Accordingly, they
believe that the tolerance for MI-CR discrepancies
is 1.5 mm in the horizontal (H) and vertical (V)
planes and 0.5 mm in the transverse (T) plane
(average: Utt and colleagues,90
2.0 mm H and V,
0.5 mm T; Crawford,88
1.0 mm H and V, 0.5 mm
T).87-91
They further contend that articulator-
mounted casts, instead of hand-held dental casts,
are the only way to discern the MI-CR discrepan-
cies. For instance, using articulator-mounted
Many prosthodontists
use retruded centric
relation only as a
guide so that dentures
can be fabricated a
millimeter or so
anterior to this
position.

dental casts, Klar and colleagues89
found a statis-
tically, but perhaps not clinically, significant
change in the pre– versus post–MI-CR recordings
(differences of no more than 0.39 mm in any of
the three spatial planes) among 200 consecutively
gnathologically treated orthodontic patients.
Lastly, gnathologically oriented orthodontists
advocate the use of the terminal hinge axis posi-
tion, the need for pretreatment CR-MI–converted
lateral cephalograms and the placement of
gnathologic positioners immediately after ortho-
dontic appliances are removed.92
On the other hand, nongnathologic orthodon-
tists tend to use hand-held models and
noninstrument-oriented CR techniques. They
favor more general treatment goals that include
the attainment of the best occlusal relationship
within the framework of optimal dentofacial
esthetics, function and stability. Furthermore,
they believe that there is a tolerance for MI-CR
slides up to 2 to 4 mm in the horizontal plane
with little or no attention given to the relevance
of the vertical and transverse dimensions.27,47,59
Orthodontic gnathologists argue that the
assessment of three-dimensional condylar posi-
tion is not possible with two-dimensional TMJ
radiography, but it is through the use of the Roth
power centric bite registration with articulator-
mounted dental casts.21-25,65,86-93
This view may
ignore the possible benefit of TMJ magnetic reso-
nance imaging (MRI) to assess condyle position.8
Nevertheless, orthodontic gnathologists believe
that it is possible to locate a particular position of
the condyles precisely in the glenoid fossa via CR
recordings.
A two-piece bite registration technique by Roth
called the “power centric bite registration” is
believed to seat the condyles in the optimal,
anterior-superior CR position—or as Utt and col-
leagues90
wrote, “condyles centered transversely
and seated against the articular disk at the pos-
terior slope of the articular eminences without
dental interferences.” Roth,21-25
Kulbersh and col-
leagues,86,87
Crawford,88
Klar and colleagues,89
Utt
and colleagues,90
Schmitt and colleagues,91
Lavine
and colleagues92
and Cordray,93
however, failed to
provide evidence (preferably MRI evidence) that
subjects’ condyles are positioned in a seated ante-
rior-superior CR. Hence, it can be argued that
there is no verification that the Roth power cen-
tric bite registration “captures” (positions and
records) condyles in anterior-superior CR.27
And
contrary to Roth’s thinking, there is evidence that
CR recordings do not place condyles in the posi-
tions stated by their advocates. Alexander and
colleagues8
provided TMJ MRI documentation
that condyles are not located in the assumed
positions as advocated and provided by several
gnathologic centric bite registrations. Centric bite
registrations attempting to locate retruded
(posterior-superior) CR and contemporary ante-
rior-superior CR do not correspond to the condyle
positions of people with asymptomatic TMD.
CR gnathologic recording techniques such as
Roth power centric bite registration and articu-
lator mounting instrumentation have been
demonstrated to be somewhat reliable (repeata-
bility and consistency of the records or tech-
niques).91,92
We, however, question the validity of
these recordings, as well as point out that there is
error in them. For instance, one study found
standard deviations for gnathologic MI-CR
records to be as high as 0.16 mm in the H and V
planes and 0.13 mm in the T plane; the error was
calculated as 0.01 to 0.05 mm.92
Because there are
only small differences between gnathologic and
nongnathologic MI-CR recorded discrepancies,
even a small amount of error calculated against
any of the gnathologic study findings would fur-
ther reduce the clinical significance of the find-
ings. Therefore, we ask if small centric MI-CR
discrepancies found by gnathologists are clinically
significant and whether they have any relation-
ship to patients’ stomatognathic health. Further-
more, the gnathologic data may be based on ques-
tionable research.27
The validity of CR recordings and the use of
articulators in orthodontics is based on the con-
cept of the terminal hinge axis. However, Pos-
selt’s94
1952 concept of a terminal hinge axis has
been challenged by Lindauer and colleagues’95
theory of simultaneous and instantaneous rota-
tion and translation of the mandibular condyles.
According to this theory, the mandibular condyles
both initially rotate and translate around an axis,
which action continues as the jaw opens.
In 1995, Lindauer and colleagues95
studied the
condylar movements and centers of rotation
during jaw opening in eight subjects without
TMD using a sonic digitizing system. They found
that all of the subjects demonstrated both rota-
tion and translation during the initial phase of
jaw opening, and none had a center of rotation at
the condylar head. Their findings support the
theory of a constantly moving, instantaneous
center of jaw rotation that is different for dif-

ferent people. Because articulators do not incorpo-
rate any initial translatory movement of the
condyles during jaw opening, Lindauer and col-
leagues95
concluded that the use of articulators to
simulate “jaw movements to identify occlusal
interferences cannot be expected to replicate the
patient’s mandibular movement precisely.” They
further argue that “the uncertainty of predicting
mandibular rotation for a given patient should be
considered when planning surgical treatment and
fabrication of orthodontic appliances.”95
DEPROGRAMMING
The need to “deprogram” patients from their pre-
existing occlusions with occlusal
splints before taking CR recordings is
controversial. Gnathologists in general
hypothesize that the mastication mus-
cles can affect adversely the
mandible’s position in the presence of
occlusal interferences owing to memo-
rized patterns and proprioceptive sen-
sory information.24
They also hypoth
esize that the condyles are prohibited
from being seated appropriately
unless a deprogramming splint pre-
cedes CR bite registrations.93
Depro-
gramming splints are thought to pro-
vide a more physiological muscular
engram than what exists by allowing the mastica-
tion muscles to mitigate temporarily the proprio-
ceptive errors caused by occlusal prematurities.21-
25,89,93
Some orthodontic gnathologists21-25,93,96-98
believe that patients, even patients without TMD,
need to be deprogrammed before their CR records
are obtained—sometimes for as long as three
months. Some orthodontic gnathologists also
argue that orthodontic patient diagnosis is not
complete unless deprogramming splints and artic-
ulator-mounted dental casts are used.21,98-100
Nonetheless, use of deprogramming splints
lacks a true physiological basis and the evidence
to support it is equivocal. While some investiga-
tions have demonstrated a possible benefit of
deprogramming,101,102
others have not.87,103
In addi-
tion, articles have discussed the techniques, bene-
fits or both of deprogramming.104-107
Both sample
studies used deprogrammers for relatively short
periods.102,103
Karl and Foley102
placed a “Lucia-
type anterior deprogramming jig” (that is, ante-
rior tooth contact without posterior tooth contact)
in 40 subjects with TMD for six hours and found
differences of only fractions of a millimeter in cen-
tric registration when a deprogrammer was used;
the difference may not be clinically significant.
Conversely, Kulbersh and colleagues87
did not
find a difference in MI-CR measurements
between orthodontic patients who wore full-
coverage deprogrammers for three weeks for 24
hours a day and those who did not.
There are many unanswered questions con-
cerning deprogramming splints.
dIs there a difference in findings between ante-
rior and full-coverage deprogrammers?
dWould a longer period of wearing a deprogram-
ming splint yield larger differences?
dAre the fractions-of-a-millimeter differences in
centric registrations produced by
deprogramming splints clinically
significant?
dHow much of the small centric
differences between depro-
grammed CR records and tradi-
tional records are due to
recording and measurement
errors?
dAre the deprogrammed
condyles being seated in the pre-
dicted glenoid fossa position?
dWhat is the reliability and
validity of deprogramming
splints for recording CR?
dIs the deprogrammed centric registration a
stable position?
dIs the deprogrammed position physiological?
dIs the deprogrammed position more physiologi
cal than the original centric position?
dDoes the deprogrammed centric position have
anything to do with stomatognathic health?
CONCLUSIONS
The definition of CR has changed over the past
half-century from a posterior and retruded
condylar position to an anterior-superior position.
The evidence suggests that condyle position and
CR position are not diagnostic of TMD. Although
dentist-manipulated CR recordings are more reli-
able than unmanipulated CR recordings, they are
less valid and physiological. Recent evidence sug-
gests that the concept of a “terminal hinge axis”
may not be valid, as there is an “instantaneous
center of rotation” in which the condyles actually
rotate and translate simultaneously. There
appears to be little benefit of using gnathologic
records and articulator-mounted dental casts to
discern MI-CR discrepancies in orthodontic
The need to
‘deprogram’ patients
from their
pre-existing
occlusions with
occlusal splints before
taking centric relation
recordings is
controversial.

patients. The use of deprogramming splints is
equivocal, with the best approximation leaning
toward the view that their use is not EB. I
A small portion of this article is reprinted from Rinchuse,27
with the
permission of the American Association of Orthodontists.
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