DOI: 10.7860/JCDR/2021/49799.

15083
Review Article

Techniques to Guide the Mandible to

Dentistry Section

Centric Relation- A Systematic Review

Sushma Ramaswamy1, Abhijeet Ramachandra Kore2, Pronob Kumar Sanyal3,

Anand Joshi4, Siddhi Hathiwala5, Prasad Nayan Tayade6

ABSTRACT position” search engines. Cochrane collaboration tool was

Introduction: Centric Relation (CR) is the only physiological used to assess the risk of bias for the Randomised Controlled
position which is repeatable, recordable and reproducible for Trial, Methodological I index for non RCTs (MINOR). Quality and
prosthodontic rehabilitation. A missed CR can give rise to strength of the existing evidence was appraised by both the
faulty occlusal relationships leading to a life time of trauma to authors through Grading of Recommendations Assessment,
the temporomandibular joints. Literature has various methods Development and Evaluation (GRADE) system.
outlined to locate and record the CR but it’s confusing as to Results: Online database search was conducted from January
which method is best suited to take the condyles into CR 1998 to September 2019 resulting in a total of 950 articles
position. Hence, this systematic review was conducted to find being shortlisted. Post-screenings, using the exclusion criteria,
an answer to this very question. nine articles of the total articles were reviewed. These were
Aim: To find a reliable clinical technique to guide the mandible reviewed individually by both the authors and discussed for
to a recordable, repeatable and reproducible CR position. various techniques to guide the mandible to CR. The ultimate
outcome of the review was that the clinicians are required to fall
Materials and Methods: The present systematic review was
back on time tested models, scientifically sound and technically
conducted from July 2019 to October 2019 at School of Dental
correct and uncomplicated to execute methods which have
Sciences, KIMSDU, Maharashtra. A 20-year comprehensive
proven to yield the most excellent outcomes at zero or minimal
literature review was undertaken aiming to arrive at a reliable
cost. One such method is undoubtedly Dawson’s Bimanual
and repeatable method to guide the mandible to CR following
Technique. Bimanual technique in supine position coupled with
the Preferred Reporting Items for Systematic Reviews and
a simple anterior deprogrammer has consistently resulted in a
Meta ​Analyses (PRISMA) and Patient Intervention Comparison
physiological CR position that is recordable, repeatable and
Outcome (PICO) guidelines to the highest possible extent.
reproducible.
The research material was sifted through MEDLINE (PubMed)-
{(“CR technique”) (MeSH terms) AND/OR (Retruded mandibular Conclusion: The primary outcome of this systematic review is
position”) (MeSH terms)}, Cochrane library “CR techniques” that Dawson’s bimanual manipulation technique is superior to
and Google Scholar “CR techniques OR Retruded mandibular other techniques; primarily when carried out in supine position.

Keywords: Centric occlusion, Condyle, Retruded mandibular position, Temporomandibular joints

INTRODUCTION it is a relationship of the maxilla to mandible in a horizontal plane or

Being the only repeatable, reproducible and recordable position to antero-posterior direction [10].
fabricate prosthesis, CR has an irreducible clinical perspective [1]. Techniques to guide the mandible to CR, the topic of this paper, have
Clinically, this is the utmost accommodating and unstrained position also seen a number of different expert views and experiments on the
of the mandible [2]. The concept of CR can find its genesis in the need fruition and success of different approaches. Worth mentioning here
for a reproducible physiological mandibular position without inimical are chin point guidance, swallowing, dawson’s bimanual technique,
ramifications on the Temporomandibular Joint (TMJ) emanating into Tongue tip to palate etc., [6-8,11]. Many research projects have also
prosthodontic rehabilitation. CR is used as the outset for fabrication of been conducted to compare several of these techniques [4,12-23].
complete dentures; full mouth rehabilitation cases either with implants Various techniques to guide the mandible to CR have also been
or Fixed Dental Prosthesis (FDPs) or distal extension Cast Partial described in textbooks [2,3,24]. Unfortunately, none of them have
Dentures (CPDs) for occlusal restoration [2,3]. Further; a missed CR been able to culminate on an evidence based single technique with
can result in erroneous restorations/ prosthesis leading to deficiency acceptable levels of repeatability and reliability [4,6-8,13,25]. Hence,
in prosthodontic treatment [4,5]. Since the inception of CR more than this systematic review has been taken up as an attempt to provide
a century ago, various aspects related to it such as its definition, an evidence based answer to fill this lacuna.
methods to register and materials to record CR have all seen constant
change. Each of these has advocates and critics alike [6-8]. MATERIALS AND METHODS
The most recent Glossary of Prosthodontic Terms (GPT 9) defines The present systematic review was performed spanning 20 years
CR as “a maxillomandibular relationship, independent of tooth from January 1998 to September 2019 and reviewed from July
contact, in which the condyles articulate in the anterior-superior 2019 to October 2019, the last search was done on 31st October
position against the posterior slopes of the articular eminences in 2019 at School of Dental Sciences, KIMSDU, Maharashtra following
this position, the mandible is restricted to a purely rotary movement; the PRISMA and Population, Intervention, Control and Outcomes
from this unstrained, physiologic, maxillo-mandibular relationship, (PICO) guidelines [26].
the patient can make vertical, lateral or protrusive movements; it is The review focussed mainly on finding a reliable technique/s to guide
a clinically useful, repeatable reference position’’[9]. To state simply, the mandible to CR position. The review has not been registered.
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Research question: Questions relating to PICO were generated

to systematically review the available literature. With regards to the
study population (P), randomised controlled trials which considered
healthy dentulous, partially edentulous, and completely edentulous
patients with no clinical signs and symptoms of TMJ disorder and
oro-facial abnormalities were included. To answer the other questions
of PICO, clinical techniques to guide the mandible to CR (I), studies
comparing two or more techniques to guide the mandible to CR
(C) were considered. Repeatable, reproducible and recordable CR
position was considered as the outcome (O).
Search strategy: The research material was sifted through MEDLINE
(PubMed)-{(“Centric Relation technique”) (MeSH terms) AND/OR
(Retruded mandibular position”) (MeSH terms)}, Cochrane library
“Centric relation techniques” and Google Scholar “Centric relation
techniques OR Retruded mandibular position” search engines.
The detailed systematic search strategy is presented in [Table/Fig-1].
The search yielded a total of 958 articles of which were 78 animals
related and 39 duplicate studies were removed leaving a total of
833 for further screening. A total of 539 studies were dropped after
studying their titles and abstracts as they did not fit the scope of this
review leaving 294 for additional scrutiny.

To find a reliable technique to guide the mandible

to Centric Relation (CR) position amongst the
Focus question ­various clinical techniques

Search strategy

Healthy dentulous, partially edentulous and/or

Population
completely edentulous patients.

Intervention Guiding the mandible to Centric Relation (CR) position.

Comparison of various clinical techniques to guide the

Comparison
mandible to Centric Relation (CR) position.

Recordable, repeatable, reproducible Centric Relation

Outcome
(CR) position.

PubMed - (“Centric Relation technique”) (MeSH terms) [Table/Fig-2]: PRISMA flow chart for article selection.
AND/OR (Retruded mandibular position”) (MeSH terms)
Search terms Cochrane Library - “Centric Relation techniques” These nine studies were then methodically checked to avoid any
Google Scholar - “Centric Relation techniques OR
Retruded mandibular position” probability of discrepancies creeping up at a later stage in the review
[12,14-18,23,27,28].
Data search electronic
MEDLINE (PubMed), Cochrane Library, Google Scholar
database use Once all and any uncertainties and doubts were laid to rest the actual
Time frame January 1998 September 2019. systematic review was undertaken. Eligibility of the relevant articles
Selection inclusion criteria to be included in the systematic review was verified independently
by two authors of this study. Any disagreement was resolved over
Articles in English Language
Studies on clinical methods of retruding the mandible. discussion with the third reviewer. The screening of the titles and
Comparative clinical studies done on healthy abstracts were done to clarify whether or not the articles were fit for
dentulous, partially edentulous, completely edentulous
Inclusion criteria patients. further reading. At the end, a thorough hand search of the selected
Comparative studies on patients with no clinical signs articles was conducted and the articles which were missed out
of TMD’s
Comparative studies on patients with no clinical signs were added. Within each included study, the following items; name
of Orofacial abnormalities of the author/s, publication date, sample size, mandibular guiding
Selection exclusion criteria techniques compared were recorded.
Non English Language articles Risk of bias assessment: Cochrane collaboration tool was used to
Surveys assess the risk of bias for the RCT’s and MINOR index for non RCT’s
Animal studies
In-vitro studies [29,30]. A statistical comparison of results and a meta-analysis was
Ex-vivo studies beyond the scope of this systematic review due to the diversity of
Radiographic studies
Exclusion criteria
Electro-myographical studies the study population, sample size, study settings. The quality and
Orthodontic studies strength of the existing evidence was appraised by both the authors
Centric Relation (CR) studies related to dental implant
CR studies on patients with clinical evidence of TMD’s
through GRADE system [31].
CR studies on patients with clinical evidence of
Orofacial abnormalities RESULTS
[Table/Fig-1]: Systematic search strategy. The selected number of articles which finally fit into the parameters
TMD: Temporomandibular diseases
of the focal question were nine [Table/Fig-3]. which describes the
Further down in the process, 285 articles were excluded based on exhaustive rundown of the selected nine articles [12,14-18,23,27,28].
the exclusion criteria. The PRISMA flow diagram for shortlisting the [Table/Fig-4] shows the risk of bias in the studies using Cochrane
articles have been shown in [Table/Fig-2]. collaboration tool [12,14-18,23,27,28].
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Author and Compared techniques (for guiding

Year Materials and methods mandible in CR) Results Conclusion Interpretation
Comparison between
•  CR (by applying distal pressure to
the chin) and CO (biting together in
Both bimanual
maximum intercuspation)
There was no statistically manipulation
•  CR and CO using Roth Power
significant difference between technique and
Total 19 healthy participants with technique. There was no
Kandasamy the measurements. Roth power
permanent dentition (14 men and •  CR (by applying distal pressure statistically significant
S et al., [12] Authors claim that asymmetric technique
five women) of 20-39 years of to the chin) and CR (Roth Power difference between the
(2013) and opposite changes were places the
age were recruited for the study. technique) techniques.
noted between left and right mandible
Both the antero- posterior and supero-
condyles. accurately in
inferior condylar positions for the
CR position.
condyles in all the above mentioned
positions (CO, CR) were measured in
the MRI scan.
•  Bimanual mandibular manipulation
Bimanual
with a jig,
manipulation
•  Chin point guidance with jig
Bimanual manipulation was Bimanual mandibular with an
•  Active (Unguided) Gothic arch
more consistent showing manipulation used with anterior jig
tracing b asking the patient to carry
Keshavd A between 10.11 and 0.438 an anterior jig gave the was the most
Total number of patients: 14 out excursive movements.
and Winstanley times less variation than the highest repeatability. accurate
(average age 26.61±4.20 years Casts were mounted on Denar D4A
RB et al., [14] gothic arch method which was Bilateral TMJ showed technique
and having complete dentition.) by means of facebow and maximum
(2003) the least consistent method. different degrees of in terms
intercuspation silicone registration
Chin point guidance was in repeatability with each of placing
record. Mandibular positional indicator
between the other two method of three CR records. condyles in
was constructed for the positional
CR position
analysis of condyles in three spatial
repeatedly.
axis.
Total 11 dentists without any
TMJ disorders were recruited for
The condylar positions
the study. Both bimanual
recorded using bimanual
CR records were made for each manipulation
manipulation repeated the
dentist by other three participant technique
Compared condylar position condylar position within
dentists. Thus three records and muscle
obtained by bimanual manipulation 0.11mm tolerance of the
(wax) for all the 11 dentists were Concluded that condylar contraction
with the condylar position obtained centric check instrument in
Mckee JR [15] made. position obtained against
from interocclusal records using 100% of the cases while
(2005) Anterior deprogrammers were through both the anterior
muscle contraction against anterior The condylar position recorded
made for each participant which techniques were similar. deprogrammer
deprogrammer with the use of using muscle deprogrammer
was worn for 60 minutes. Then, places the
condylar position indicating device. repeated the condylar position
each participant of the group mandible
within 0.11mm tolerance of
had four different interocclusal accurately in
the centric check instrument in
wax records. (three in reclined CR position.
97.7% of the cases.
position and one in
Upright position.)

In the sagittal plane:

a. On the left- both BM
(bimanual position) and NM
(Non manipulation) was located
posterior and inferior to inter-
cuspal position ICP.
Both bimanual
Compared the bimanual operator b. On the right: For the BM
operator
guidance and unguided mandibular the condyles were positioned Concluded that there
Total 37 healthy participants guidance and
stationary hinging at final jaw closure. posterior and inferior to ICP was statistical but
(19 men 18 women) aged 23- unguided
Celar A et al., Electronic condylar position indicator and for NM the condyles were not clinically relevant
32 years with complete dentition mandibular
[16] (2013) measured the position of the condylar positioned, Anterior and Inferior difference between the
without the third molars were stationary
spheres with six measuring gauges compared to ICP. repeatability of the two
chosen for the study. hinging
that displayed XYZ spatial coordinates BM was not significantly methods.
have similar
of the left and right condylar positions. different from ICP.
accuracy.
NM was significantly more
caudal than ICP.
BM and NM differed
significantly in all directions
except antero-posteriorly on
the right side.

The 30 patients were divided into three

Bimanual
groups according to the method of
manipulation
guiding to CR applied Bimanual manipulation
method was
Group A: Swallowing method There was no significant method was found to
Kazanji M et al., Total 30 edentulous patients the most
Group B: Chin point guidance was difference in the mean of the be the most repeatable
[17] (2014). aged between 45-65 years. repeatable
used. different methods, technique with least
technique
Group three: Bimanual manipulation variations.
with least
was used to guide the mandible into
variations.
CR.

Total 60 patients were divided into

two groups depending on the method
Total 60 completely edentulous
applied to retrude the mandible into The mean time Both bimanual
patients.
CR. taken in group 1 manipulation
Group 1 had 19 male and There was statistical difference
Group 1: A new technique: wax ball was 56.47+75.368 technique
11 female participants in time taken between both the
technique was used to retrude the years and mean time and new wax
Sushma R et Group 2 had 17 male and techniques but no statistical
mandible. taken in group 2 was ball technique
al., [18] (2019) 13 female participants. difference between the two
Group 2: Dawson’s bimanual method 5.97±2.042 years. places the
The average age of participants techniques when accuracy was
was used to retrude the mandible. Both the techniques mandible
in group 1 was 58.33±11.874 compared.
The time taken to register the CR in were found to be accurately in
years and for group 2 it was
both the techniques and the accuracy accurate. CR position.
61.17±12.157 years
of both the techniques were compared
in this study.

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1. T
 here was no statistically
significant difference among Both bimanual
the methods for recording manipulation
lateral displacement. Concluded that technique
•  Compared swallowing technique 2. S
 wallowing method differed swallowing method and chin point
Total 10 patients aged 25 to
Alvarez MC et with chin point guidance method. significantly from other produced smaller guidance
39 years were recruited for the
al., [23] (2009) •  Compared swallowing technique methods for anteroposterior mandibular posterior technique
study.
with Bimanual manipulation (AP) displacement; however, displacements than the place the
there was no difference other methods. mandible
between chin point guidance accurately in
and bimanual manipulation CR position.
in the AP direction.

•  Supine position is
better for recording
CR.
•  CR recorded by
Total number of patients: 26. Both in Group A and B, the
unguided Gothic
Group A (N=16) had maxillary LGTP were distributed 0.2 to 0 Bimanual
arch tracing matches
edentulous ridges and lower mm anterior and 0.02 mm manipulation
•  Active (Unguided) Gothic arch the CR recorded by
partially edentulous arches. lateral to the bilateral technique
tracing in upright and supine position bimanual manipulation
Group B (N= 10) had both manipulation. A variation range primarily
Watanabe Y •  Light Guide Tapping Position (LGTP) in supine position.
maxillary and mandibular of 0 to 0.6 mm was found in in supine
[27] (1999) in upright and supine position. •  Although LGPT in
edentulous arches. both the bilateral manipulation position gave
•  Bimanual manipulation in upright upright position
Tracers attached to the lower and LGPT. Approximately 60- better results
and supine position. showed variable
arches had sensors attached 80% of the variation was within than other
results; in supine
to it and the readings were 0.2mm in the anteroposterior techniques.
position it matched
recorded real time in computer. and lateral direction.
closely with that of
bimanual manipulation
and gothic arch
tracing.

•  CR position obtained

with swallowing
The mandibular position
technique place
in the sagittal plane during
mandible more
swallowing was significantly
anterior compared to
more anterior than CR in all
bimanual manipulation
•  Compared bimanual manipulation subjects.
technique. Bimanual
and swallowing method to record The VDO determined with the
Total 15 healthy subjects (six •  Swallowing technique manipulation
the CR swallowing technique was
Millet C et al., men and nine women) between is not recommended technique gave
•  Compared swallowing and 21.8± 1.6 mm. VDO obtained
[28] (2003) 45 to 81 years (mean age of 63+ to record CR better results
traditional technique (Niswonger’s by means of the traditional
years. •  VDO obtained than other
method) to record vertical dimension method was 20.0±0.5 mm.
with swallowing is techniques.
and CR The VDO determined with
higher (1.8mm) than
the swallowing method was
VDO obtained with
statistically higher (1.8 mm)
traditional technique.
than the VDO obtained with the
•  Swallowing technique
traditional method.
can be used to record
the VDO.
[Table/Fig-3]: Studies included in the systematic review.
CR: Centric relation; CO: Centric occlusion; TMJ: Temporomandibular joint; ICP: Intercuspal position; VDO: Vertical dimension of occlusion, MRI: Magnetic resonance imaging

to CR position. Nine articles included for this review were all original
studies, done in a clinical setup, comparing two or more techniques
to guide the mandible to CR position.
The patients recruited in all the studies were healthy individuals,
without any TMJ disorders or deformities in oral and maxillofacial
region. Of the nine selected articles, four articles studied edentulous
patients while the other five articles did examination on dentulous
patients. A total of 222 subjects had participated in these nine
studies, of which 115 patients were entirely edentulous and 16 were
partially edentulous; while remaining 91 were dentulous.
Watanabe Y loaded the horizontal position data on a personal
computer with the help of sensors attached to the gothic arch
tracing. CR position obtained with excursive mandibular movements
and recorded with gothic arch tracing, bimanual manipulation
and chin point guidance in both supine and upright positions.
From this comparison, it was inferred that bimanual manipulation
technique in supine position gave reliable and repeatable results
[27]. Comparable results were obtained in the study done by
Keshvad A and Winstanley R where bimanual manipulation, chin
point guidance with a jig and gothic arch tracing were compared.
Bimanual manipulation was found to be a superior technique when
[Table/Fig-4]: Risk of bias assessment. used along with anterior jig in all three axis, while gothic arch tracing
was the least repeatable [14].
DISCUSSION The anterior deprogrammer is a flat plane occlusal splint with an
The present systematic review was designed to identify published anterior acrylic block designed to disocclude the posterior teeth. It
articles comparing the diverse techniques for guiding the mandible eliminates the patient’s neuromuscular avoidance mechanism and
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www.jcdr.net Sushma Ramaswamy et al., Techniques to Guide the Mandible to Centric Relation

helps him/her to acquire CR position without assistance. The use the tongue to posterior most orientation wax ball and close on the
of the deprogrammer and the action of the elevator muscles allow occlusal rims thus guiding the mandible to CR. The two techniques
seating of the condyles in an anterior-superior position [32]. An were compared based on timings required to record CR accuracy.
anterior programming device helps separation of the posterior teeth It was found that both techniques recorded CR accurately with
immediately prior to CR record fabrication which helps in the patient insignificant difference between the two techniques. Also, the wax
“forgetting” the established protective reflexes. Cotton rolls, plastic ball orientation technique required significantly lesser time than the
leaf gauge, oral small device made of autopolymerising acrylic resin bimanual manipulation technique to record CR [18].
placed between the maxillary and mandibular anterior teeth can be Bimanual manipulation technique: Among the nine studies included
used as an anterior deprogramming device [33]. This results in an in this systematic review, 8 studies compared bimanual manipulation
anterior stop that acts as a fulcrum which directs the force provided technique with one or two other techniques. This passive technique
by the elevator muscles to seat the condyles in CR position. This of recording CR was described by Long JH and then modified and
coupled with the Dawson’s bilateral mandibular manipulation popularized by Peter Dawson [36,37]. Bimanual manipulation is
technique has shown to result in a greater mandibular displacement considered as an accurate and reliable method for placing condyle in
from the intercuspal position than with a CR record alone. It turns glenoid fossa in CR position by many researchers [15,18,19]. Further,
the rigid muscles of a ‘clencher’ to butter [33-35]. some studies observed that this technique gave the most reproducible
In the study done by Millet C et al., swallowing technique was used and repeatable results [8,14,23]. The results of six studies reported
as a technique to record both vertical and horizontal jaw relation in this systematic review concluded that bimanual manipulation
and was compared to bimanual manipulation technique. It was technique was better than the other compared techniques.
noted that swallowing provides an occlusal zone and not merely a In this technique, the dental chair is reclined and the patient’s head
single position and hence cannot be used as a reference position in is cradled by the examiner. With the help of both thumbs on the chin
sagittal plane to record the CR position [28]. and the fingers resting firmly on the inferior border of the mandible,
In his study, McKee JR compared the position of condyles achieved downward pressure is exerted by the examiners thumb and upwards
by Dawson’s bimanual manipulation and masticatory muscle pressure on the fingers thereby manipulating the condyle-disk
contraction against an anterior deprogrammer with the help of assembly in their fully seated positions in the mandibular fossae,
condylar position indicating device. Condylar position achieved by after which the mandible is carefully hinged along the arc of terminal
both the techniques against an anterior deprogrammer was the hinge closure [37]. Dawson claims bilateral manipulation is the only
same, when there were no influences from occluding teeth [15]. appropriate method to position the mandible in CR. In one of his
Another study included in this systematic review compared inter- studies, it was established that more than 3000 dentists preferred
maxillary relationships with manual (chin point guidance), swallowing bilateral manipulation technique [38].
and bimanual methods by Alvarez MC et al., [23]. There was no This technique positions the mandible posteriorly while concurrently
significant difference found between chin point guidance and directing force supero-anteriorly on the condyles providing:
bimanual manipulation. However; there was a significant inference
• A swift corroboration of correctness of the position.
that, when used in combination with anterior jig or leaf gauge, all
methods guide the mandibular condyles to the CR position. Among • Alignment of condyle-disk assembly.
the three techniques evaluated, it was found that swallowing • Integrity of articular surfaces, all the while being quick and
technique was dependent on patient and could cause inaccurate straightforward.
position in presence of occlusal interference. Celar A et al., studied This goes on to show the pre eminence of this technique over
guided and unguided mandibular positions in asymptomatic the other jaw manipulation methods. Once the correct skills are
patients. Bimanual manipulation was compared to unguided jaw acquired, the CR position can typically be located and verified within
closure with reference to spatial relationship of condyle positions, a few seconds, all the while giving the operator excellent control
repeatability over time and operator influence. The Non Manipulated over jaw movement [37,38].
(NM) technique placed condyle about 0.6 mm (average) anterior
Chin point guidance is a passive method of recording CR described
and inferior to the position obtained by bimanual manipulation. The
by Ramfjord and Ashand, Ash and Ramfjord, and first reported in
differences in position were within tolerance of biological system.
literature by McCollum BB [39]. Previously, it was also called as “3
Proper exercise and guidance to the patient prior to recording the
Finger” method as the thumb, index finger and middle finger were all
centric position resulted in almost similar reproducibility in both the
placed on the chin and the mandible was pushed as far posterior as
techniques [16].
possible. The method was then modified with the thumb placed on
Kandasamy S et al., assessed condylar position by Magnetic
the middle of chin and the other two fingers supporting the mandible
Resonance Imaging (MRI) after common bite registrations; centric
inferiorly [14]. According to Keshavd A and Winstanley RB, Alvarez
occlusion, retruded CR and roth-power CR. The study failed to
MC et al., Watanabe Y, chin point guidance technique could be used
sustain the claim that certain bite registrations could accurately
for recording CR with almost similar accuracy as that of bimanual
position the condyles in specific position in glenoid fossa [12]. Kazanji
method [14,23,27].
M et al., at checking reproducibility of three different techniques:
bimanual manipulation, swallowing and chin point guidance. All the Swallowing is an active method of guiding the mandible to CR
three techniques gave acceptable results however; the bimanual [40]. Niswonger mentioned that during swallowing mandible travels
manipulation technique gave the most repeatable and reproducible from rest position to CR and back to the rest position [6]. Kurth LE
result [17]. used the swallowing reflex in determining CR [22]. Swallowing or
Sushma R et al., in a recent study compared bimanual manipulation free closure technique was advocated by Shanhan TEJ [41]. While
technique with a new copyrighted technique (wax ball orientation some authors advocate the swallowing technique for recording
technique). The technique involved a modification of the record CR, few others state that CR differs from a swallowing position
base wherein three orientation wax balls were fabricated on the [6,41-43]. Numerous studies conclude that while swallowing the
record base; one behind the incisive papilla, the second one in line mandible never moves back to the terminal hinge position but
with the premolar region and the last one at the posterior border remain slightly anterior to it [23,31,44,45]. Conversely, a minority
of the record base near the posterior palatal seal region in line with of studies question the applicability of the swallowing technique
the second molars. Patients were trained initially and once they for guiding the mandible to CR principally because of the various
were comfortable with the technique, were asked to touch the tip of results it produces [3,23,28].
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Gothic arch technique: Gothic arch technique was used in two of the best method to guide the mandible to CR. This review addresses
the studies done by Keshavd A and Winstanley RB and Watanabe that question using the PICO format. The data extraction was
Y [14,27]. Arrow point tracing or needle-point tracing or gothic arch charted out clearly and performed independently by two authors
tracing is an active method of guiding mandible to CR and was first and any discrepancy found was resolved by consulting the third
introduced and popularised by Gysi [6]. Gysi developed this method author. Though the general consensus seems to direct the choice
as an extraoral tracing technique which was later modified by Gerber of technique on numerous factors such as clinician’s judgement,
et al., to an intraoral technique both having their own advantages and expertise, experience and patient related factors, this review points
disadvantages. In this technique, the CR registration was not considered at one particular evidence-based technique being far more superior
correct until the apex of the tracing was sharp and thin [40]. to others considering the repeatability, reliability and outcome.
Power centric bite registration by Roth RH otherwise known as the
Roth power technique is “a two-piece wax registration method”. It Limitation(s)
is understood to place the condyle in the optimal anterior superior Firstly, the time frame selected for this systematic review was
CR position. In this technique patient’s own musculature is utilised pretty long i.e. 20 years while only 9 articles could be selected
to guide the mandible into CR when resistance is applied in the for the review after the application of all the required criteria.The
anterior region [46]. It is recorded with a 2- piece wax registration other limitation of the study was that a meta-analysis could not be
consisting of anterior and posterior sections. The anterior section conducted because of variations in the study population, sample
is first constructed at a vertical vis-à-vis the posterior teeth, at least size, study settings. Also, the number of patients allocated in each
2 mm apart. This piece of wax is frozen and allowed to harden. study was less for application on a large population. Hence, there is
a scope to study the different technique to prove the superiority on
The wax is then placed back into the mouth after which a softened
a large population.
posterior section is positioned, and the patient is instructed to bite.
The mandibular anterior teeth are guided into the toughened anterior
section of wax without a slide in the indentations. As the patient CONCLUSION(S)
closes onto the hardened anterior section, he or she is instructed to The primary outcome of this systematic review is that Dawson’s
“close firmly and clutch.” When the posterior section which is chilled bimanual manipulation technique is better than other techniques
with air hardens sufficiently to prevent distortion, both wax sections especially when carried out in supine position. Irrespective of the
are then removed and chilled [47]. technique used to guide the mandible to CR, clinicians should prefer
supine position over an upright position. Muscle deprogramming
Active vs Passive techniques [Table/Fig-5]: According to some with anterior jig or leaf gauge before guiding the mandible to CR gives
researchers, active (unguided) method of guiding mandible to CR superior results. At the bleeding edge of technology, the science
is superior to passive (guided) method. However; the supporters of dentistry is being shaped and reshaped at a break neck speed
of passive method agree that pressure for guiding the mandible and Prosthodontics is no exception. Innovations in diagnostics,
should not be heavy as it causes discomfort to the patients resulting advances in material sciences, and sophistication in biomedical
in muscular activity for self-protection leading to protrusion of lower engineering has ushered in a new dawn in the field of dentistry.
jaw [6,20,21]. On the contrary, the articles reviewed in this systematic The nascent stages of some of these advancements also bring in
review observed that the most repeatable technique to record CR is the burden of elevated costs for both clinicians and patients. Some
bimanual manipulation which is a passive method. developments stay prohibitively expensive for a long time for them
to be accepted as a part of main stream treatment methodology,
especially so in the developing and under developed countries.

REFERENCES
[1] Palaskar JN, Murali R, Bansal S. Centric relation definition. A historical
and contemporary prosthodontic perspective. J Indian Prosthodontic Soc.
2012;13(3):149-53.
[2] Zarb GA, Bolender CL. Prosthodontic treatment for edentulous patients. 12th ed.
St. Louis: CV Mosby; 2004: pp 268-297.
[3] Winkler S. Essentials of complete denture prosthodontics. 2nd ed. IEA. Delhi,
India: AITBS Publishers; 2000: pp192-193.
[4] Kantor EM, Silverman SI, Garfinkel L. Centric relation recording techniques- A
comparative investigation. J Prosthet Dent. 1972;28(6):593-600.
[5] Hughes GA, Regli CP. What is centric relation? J Prosthet Dent. 1961;11(1):16-22.
[6] Keshavd A, Winstanley RB. An appraisal of the literature on centric relation
Part 1. J Oral Rehabil. 2000;12(10):823-33.
[7] Keshavd A, Winstanley RB. An appraisal of the literature on centric relation
Part 2. J Oral Rehabil. 2001;27:1013-23.
[8] Keshavd A, Winstanley RB. An appraisal of the literature on centric relation Part
3. J Oral Rehabil. 2001;28(1):55-63.
[9] Academy of denture prosthetics. The Glossary of Prosthodontic Terms: 9th ed.
J Prosthet Dent. 2017;117(5S):01-105.
[10] Turp JC, Schindler HJ, Rodiger O, Smeekens S, Marienello CP. Vertical and
horizontal jaw relations in reconstructive dentistry- A critical review. Schweiz.
Monatsschr. Zahnmed. 2006;116(4):403-17.
[11] Campos AA, Nathanson D, Rose L. Reproducibility and condylar position of
a physiologic maxillomandibular centric relation in upright and supine body
position. J Prosthet Dent. 1996;76(3):282-87.
[12] Kandasamy S, Boeddinghaus R, Kruger E. Condylar position assessed by
magnetic resonance imaging after various bite position registrations. Am J
Orthod Dentofacial Orthop. 2013;144(4):512-17.
[Table/Fig-5]: Various techniques to Guide the mandible to Centric Relation (CR) [13] Thakur M, Jain V, Parkash H, Kumar P. A comparative evaluation of static and
position [2,3,24]. functional methods for recording centric relation and condylar guidance: A clinical
study. J Indian Prosthodont Soc. 2012;12(3):175-81.
Strength of this systematic review: This systematic review [14] Keshavd A, Winstanley RB. Comparison of the replicability of routinely used
centric relation registration techniques. J Prosthodont. 2003;12(2):90-101.
addresses one of the most contentious topics in dentistry in general
[15] Mckee JR. Comparing condylar positions achieved through bimanual manipulation
and prosthodontics in particular. In spite of the availability of rich to condylar positions achieved through masticatory muscle contraction against
literature, there always has been a pertinent question as to which is an anterior deprogrammer. J Prosthet Dent. 2005;94(4):389-93.

6 Journal of Clinical and Diagnostic Research. 2021 Jul, Vol-15(7): ZE01-ZE07

www.jcdr.net Sushma Ramaswamy et al., Techniques to Guide the Mandible to Centric Relation

[16] Celar A, Freudenthaler J, Crismani A, Graf A. Guided and unguided mandibular [31] Guyatt GH, Oxman AD, Schnemann HJ, Tugwell P, Knottnerus A. GRADE
reference positions in asymptomatic individuals. Orthod Craniofac Res. guidelines: A new series of articles in the journal of clinical Epidemiology. J Clin
2013;16(1):28-35. Epidemiol. 2011;64(4):380-82.
[17] Kazanji M, Habib S, Qadir A. Reproducibility of centric jaw relation record for [32] Hunter BD II, Toth RW. Centric relation registration using an anterior deprogrammer
edentulous patients. Duhok Med J. 2014;8(1):61-67. in dentate patients. J Prosthodont. 1999;8(1):59-61.
[18] Sushma R, Roy MS, Sanyal PK, Joshi A, Vande A, Kore AR. A clinical comparative [33] Land MF, Peregrina A. Anterior deprogramming device fabrication using a
study to assess the efficacy of a new centric registration technique with a thermoplastic material. J Prosthet Dent. 2003;90(6):608-10.
conventional technique. J Indian Prosthodont Soc. 2019;19(4):290-95. [34] Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed.
[19] McKee JR. Comparing condylar position repeatability for standardized v/s St. Louis: Elsevier; 2000. Pp. 38.
non-standardized method of achieving centric relation. J Prosthet Dent. [35] Lucia VO. A technique for recording centric relation. J Prosthet Dent.
1997;77(3):280-84. 1964;14(3):492-505.
[20] Bansal S, Palaskar J. Critical evaluation of various methods of recording centric [36] Long JH. Location of terminal hinge axis by intra oral means. J Prosthet Dent.
jaw relation 2008;8(4):185-91. 1970;23(1):11-24.
[21] Bansal S, Palaskar J. Critical evaluation of methods to record centric jaw relation. [37] Dawson PE. Relation centric: Its effect on occluso-muscle harmony. Dent Clin
J Indian Prosthodon Soc. 2009;9(3):120-26. North Am. 1979;23(2):169-80.
[22] Kurth LE. Methods of obtaining vertical dimensions and centric relation: A [38] Dawson PE. Functional Occlusion: From TMJ to smile design. St. Louis: CV
practical evaluation of various methods. J Am Dent Assoc. 1959;59(4):669-73. Mosby; 2007: pp. 57-68.
[23] Alvarez MC, Turbino ML, Barros C, Pagnano VO, Bezzon OL. Comparative study [39] McCollum BB. Function factors that make the mouth & teeth a vital organ. J Am
of Intermaxillary relationships of manual and swallowing methods. Braz Dent J. Dent Assoc. 1972;14:1261-71.
2009;20(1):78-83. [40] Gerber A, Steinhardt G, Carmichael RP. Dental occlusion and the temporo-
[24] Rangarajan V, Padmanabhan TV. Textbook of Prosthodontics. 2nd ed. New Delhi: mandibular joint. Chicago, Quintessence; 1990: 92-94.
Reed Elsevier India Pt. Ltd; 2017: pp. 98-132. [41] Shanhan TEJ. Physiologic jaw relations and occlusion of complete dentures.
[25] Chander NG. Evidence based research in prosthodontics. J Indian Prosthodontic J Prosthet Dent. 2004;91(3):203-05.
Soc. 2016;16:113. [42] Abdel-Hakim AM. The swallowing position as a centric relation record. J.
[26] Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Prosthet. Dent. 1982;47(1):12-15.
reporting items for systematic review and meta-analysis protocols (PRISMA-P) [43] Celar AG, Kundi M, Piehslinger E, Furhauser R, Kohlmaier B. Mandibular
2015 statement. Syst Rev. 2015;4(1):01-09. position at chin point guided closure, intercuspation and final deglutition in
[27] Watanabe Y. Use of personal computers for gothic arch tracing: Analysis and asymptomatic and temporomandibular dysfunction subjects. J Oral Rehabil.
evaluation of horizontal mandibular positions with edentulous prosthesis. J 2000;27(1):70-78.
Prosthet Dent. 1999;52(5):562-72. [44] Kydd WL, Sander A. A study of posterior mandibular movements from inter-
[28] Millet C, Jeannin C, Vincent B, Malquarti G. Report on the determination of cuspal occlusal position. J Dent Res. 1961;40(3):419-25.
occlusal vertical dimension and centric relation using swallowing in edentulous [45] Sheppard IM, Sheppard SM. Denture occlusion. J Prosthet Dent.
patients. J Oral Rehabil. 2003;30(11):1118-22. 1971;26(5):468-76.
[29] Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane [46] Roth RH. Gnathologic considerations for orthodontic therapy in: Mc Neil C (ed),
Handbook for Systematic Reviews of Interventions version 6.0 (updated July Science and practice of occlusion, II, Quintessence publishing: 1997;506-507.
2019). Cochrane. 2019. www.training.cochrane.org/handbook. [47] Schmitt ME, Kulbersh R, Freeland T, Bever K, Pink FE. Reproducibility of the Roth
[30] Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological power centric in determining centric relation. Semin Orthod. 2003;9:102-80.
index for non-randomised studies (minors): Development & validation of a new
instrument. ANZ J Surg. 2003;73(9):712-16.

PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India.
2. Associate Professor, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India.
3. Professor and Head, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India.
4. Professor, Department of Physiology, Krishna Institute of Medical Sciences, KIMSDU, Satara, Maharashtra, India.
5. Associate Professor, Department of Public Health Dentistry, New Horizon Dental College and Research Institute, Bilaspur, Madhya Pradesh, India.
6. Postgraduate Student, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Anand Joshi, •  Plagiarism X-checker: Apr 09, 2021
Krishna Institute of Medical Sciences, Karad, Maharashtra, India. •  Manual Googling: Apr 12, 2021
E-mail: doc.sushma.r@gmail.com •  iThenticate Software: Jun 04, 2021 (15%)

Author declaration:
•  Financial or Other Competing Interests:  None Date of Submission: Apr 07, 2021
•  Was Ethics Committee Approval obtained for this study?  NA Date of Peer Review: May 04, 2021
•  Was informed consent obtained from the subjects involved in the study?  NA Date of Acceptance: May 27, 2021
•  For any images presented appropriate consent has been obtained from the subjects.  NA Date of Publishing: Jul 01, 2021

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