CLASSIC ARTICLE

Factors inuencing centric relation records in edentulous mouths

A. Albert Yurkstas, BS, MS, DMD,* and Krishan K. Kapur, BS, BDS, MS, DMD** Tufts University School of Dental Medicine, Boston, Mass

umerous methods of registering centric relation have been described in the literature.1-9 They can be classied as (1) static, (2) graphic, (3) physiologic or functional, and (4) cephalometric. Two of the most popular methods of registering centric relation are the intra-oral Gothic arch (needle-point) tracing, and the wax recording procedure. Both of these methods have been criticized for their inaccuracies. Hanau10 pointed out the resilient and like effect, Realeff, of the supporting tissues as the chief source of error in registering maxillomandibular relationships. In order to minimize the inuence of this factor, Hanau11 and Wright5 advocated that the registration of centric relation be made under minimum pressure or, when possible, with zero pressure. Wright5 further suggested the use of stabilized baseplates for more accurate registrations. It is axiomatic to state that registrations are no more accurate than the bases used in their execution. Gysi,12 in criticizing the reliability of the wax recording techniques, stated that no two check bites obtained by wax or compound were alike. He indicated that this was due to the uneven consistency of the occlusion rims, which resulted in uneven pressures on the denture supporting tissues. Trapozzano13 maintained that the wax recording method was the most accurate method because of the greater ability to equalize or centralize pressure with this technique. The intraoral tracing procedure has also been criticized by many prosthodontists. Their main objections were based on the general disadvantages of a central bearing point device. Trapozzano13 stated that the use of the central bearing point is based on the fallacious assumption that the central bearing point will produce equalization of pressure. Equalization of pressure with a central bearing point will result, only if two conditions are present: (1) if normal ridge relations exist and the central point of bearing can be placed in the center of the maxillary and mandibular foundational bases and (2) if mucosal resiliency is extremely slight. Kingery14

pointed out that the central bearing point did not allow for control over the amount of closing pressure that the patient could apply during the registrations. Payne15 has called attention to the fact that the introduction of any apparatus into the mouth may lead to discrepancies. Some of the factors that inuence the recording of centric relation are presented in Table I. According to the available dental literature, most clinicians were in agreement that the amount of pressure exerted during registrations was a major inuencing factor on reliability of the various recordings. Boucher16 demonstrated the vertical error introduced by the use of the central bearing point when eccentric registrations were made and advocated the use of lateral and incisal bearing points for the respective eccentric positional registrations. The literature, however, contained no quantitative experimental evidence regarding the inuence that different factors played on the reliability of various techniques for registering centric relation. This study was carried out to evaluate the effect of various factors on the reliability or duplicability of two methods used in recording centric relation. The wax recording and the intraoral tracing procedures were the two methods studied. The basic premise used was that the more accurately a record could be duplicated the more likely it was to be correct. The experimental conditions under which these tests were made are listed in Table II.

EXPERIMENTAL PROCEDURE
Thirty-ve edentulous patients were selected at random. Stabilized recording bases made from the reinforced shellac baseplates with zinc oxide and eugenol paste linings over tin foil that was burnished on the nal casts were prepared for each patient. An evaluating tripod (Fig. 1) was used to record the amount of deviation in each recording procedure.17,18 It consisted of a tripod instrument similar to the Hooper duplicator, modied to facilitate the accurate recording of changes exhibited by various registrations. A Hanau type of mounting ring was attached to the upper element by means of a center bolt, machined so that one full revolution would raise or lower the ring 1.0 mm. The three legs of the tripod were tipped with pointed tool steel cylinders, which could be moved up and down independently. The base of the
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Read before the Academy of Denture Prosthetics in Minneapolis, Minn. *Chairman of the Department of Complete Dentures. **Associate Professor Dental Science. Presently, Director of Research, University of Detroit, School of Dentistry. Reprinted with permission from J Prosthet Dent 1964;14:1054-65. J Prosthet Dent 2005;93:305-10.

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Table I. Factors inuencing centric relation records

1. The resiliency of the supporting tissues 2. The stability of the recording bases 3. The temporomandibular joint and its associated neuromuscular mechanisms 4. The character of the pressure applied in making the recording 5. The technique used in making the recording and the associated recording devices used 6. The skill of the dentist 7. The health and cooperation of the patient 8. The maxillomandibular relationship 9. The posture of the patient 10. The character or size of the residual alveolar arch 11. The amount and character of the saliva 12. The size and position of the tongue

Table II. Variables tested

A. Wax Recording Technique 1. Consistency of wax a. Recording waxes of different hardnesses b. Variation in degree of softness of wax on both sides c. Variation in degree of softness of wax on each side 2. Amount of occlusal contact a. Recording wax over the entire ridge b. Recording wax in posterior portion (1) with anterior freedom (2) without anterior freedom B. Intraoral Tracing Procedure 1. Location of the central bearing point a. Bearing point centralized to tracing plate b. Bearing point located 6.0 mm. anterior to the center c. Bearing point located 6.0 mm. posterior to the center d. Bearing point located 6.0 mm. lateral to the center 2. Inclination of the central bearing point a. Perpendicular to the tracing plate b. Inclined 15 degrees posteriorly c. Inclined 15 degrees anteriorly d. Inclined 15 degrees laterally 3. Inclination of the tracing plate a. Tracing plate parallel to the bearing portions of the lower posterior ridge b. Tracing plate inclined 15 degrees anteriorly c. Tracing plate inclined 15 degrees posteriorly d. Tracing plate inclined 15 degrees laterally 4. Amount of pressure exerted a. Extremely light contact b. Deliberate heavy contact 5. Type of ridge a. Well-developed b. Flat

instrument had a mounting table and three projecting arms with 1.0 mm. grids inscribed on the steel squares xed at their extremities. The exact center of the grid was pitted and the pointed ends of the tripod tted exactly in the center of each grid. The variations noted during the experimental procedures were recorded on millimeter graph paper. Any change in the original occlusal vertical dimension was noted by adjustments needed on the center adjustment screw whereas the registration of so-called tilting where one or more legs did not touch the grid was recorded by means of a machinists ller gauge placed between the leg of the tripod and the grid. A geometric projection was accomplished to transpose the values at each leg of the tripod to a single value of deviation at the exact center of the evaluating tripod. These single center values were used in the statistical analysis.

WAX RECORD PROCEDURE

Hard wax occlusion rims were prepared on the upper and lower stabilized baseplates utilizing a previously determined occlusal vertical dimension which was held constant throughout the experimental procedure. The approximate center of the lower arch was determined geometrically, and a hole was made through the lower cast with a No. 10 round bur. The lower cast was mounted to coincide with the center of the evaluating tripod at a point equidistant from the recording points or center points of the arms of the instrument. The upper cast was mounted in the instrument by means of a control standard wax record technique. The mandibular occlusion rim was shortened approximately 2 mm., and keys were cut into the upper and lower occlusion rims. Two small rectangular pieces of softened beeswax were then placed in the molar and bicuspid regions of the lower occlusion rim. These were pooled with a wax spatula and tempered in warm water. Extreme care was taken to make certain that they approached the same consistency. The patient was asked
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to raise and retrude the tip of his tongue and touch the posterior palatal edge of his upper baseplate. He was then instructed to close until the previously determined occlusal vertical dimension was reached. The vertical dimension of occlusion was checked by means of nose and chin guide points. No contact existed in the anterior region from cuspid to cuspid. This record was used to mount the upper cast. Three more records were made in a similar manner, and the deviations were recorded. The mean and standard deviation of the values were calculated for the control wax recording procedure. They were used to compare with the standard deviations of the results obtained when each variable was introduced. Five patients were used for each variable studied, and triplicate records were obtained. The order of presentation was carefully randomized so as to preclude the inuence of learning and fatigue.

INTRAORAL TRACING PROCEDURE

The lower cast was mounted as previously described. The upper cast was mounted with the use of a control intraoral tracing procedure. This consisted of placing
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Fig. 1. The recording instrument. The evaluating tripod used for recording the amount of deviation of the various techniques for registering centric relation. Variation in interocclusal records is observed by movement of the tripod arms when different interocclusal records are introduced between the casts.

Fig. 2. Scatter of the various types of wax registrations. The bar graphs indicate a comparison (standard deviation) of variables tested in the wax recording procedure. The mount of lateral displacement is indicated superiorly to the baseline, and the amount of anteroposterior displacement is indicated inferiorly to the baseline.

Table III. Critical ratios of various wax procedures

a tracing plate parallel to the bearing portion of the lower ridge. An effort was made to divide the maxillomandibular space evenly. The central bearing point was positioned as close as possible to the center of the lower bearing area. It was also placed perpendicular to the tracing plate. A thin lm of blue inlay wax was coated on the rigid mandibular tracing plate. The patient was instructed to exert light pressure and to move his jaw from one side to the other with an occasional protrusive movement. In this way a needle-point tracing was obtained. When a denite apex was scribed, an aluminim disc with a small hole in the center was placed so that the apex of the needle-point tracing coincided with the center of the hole. This disc was luted in position with sticky wax, and the recording rims were returned to the patients mouth. He was then requested to engage this small hole in the disc with the central bearing point and to hold the two recording rims together as lightly as possible. Quick setting impression plaster was then injected between the two recording rims from a plaster syringe. The plaster was allowed to set, and the recording rims were removed. The initial mounting was then made with the aid of this recording. Three other recordings were made in the same manner. The mean and standard deviation of the values were calculated for each procedure used. Again 5 patients were evaluated for each variable studied (Table II).
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Soft vs. medium wax Soft vs. hard wax Moderate vs. hard wax Soft beexwax pooled on both sides vs. soft wax warmed on both sides Soft wax pooled on both sides vs. soft wax pooled on one side and warmed on the other Soft wax over entire ridge Soft wax with anterior freedom vs. anterior contact 1% Signicance

CR = 3.8 CR = 3.70 CR = 1.01 CR = 4.87 CR = 3.61 CR = 3.93 CR = 4.13 CR = 2.56

RESULTS
Fig. 2 is a bar graph illustrating the standard deviation of the records obtained by means of various wax recording procedures. The control wax recording method showed the least variability when compared to the records obtained with the use of a moderately hard or a hard wax for registration. A statistical analysis was accomplished to determine the signicance of these differences according to a method described by Garrett.19 The means, standard deviations, and critical rates were computed and are listed in Table III. There was a signicant difference in values obtained with soft wax as compared to those obtained when hard or moderately hard wax was used. No signicant
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Fig. 3. Bar graphs indicate the percentage of various wax registrations that show vertical discrepancies.

Fig. 4. Scatter in the various types of intraoral tracing procedure registrations. The bar graphs indicate a comparison (standard deviations) of the variables tested in the intraoral tracing procedure registrations. Table IV. Critical ratios of intraoral tracing procedures
Location of Central Bearing Point Anterior displacement vs. standard Lateral displacement vs. standard Posterior displacement vs. standard Inclination of Central Bearing Point Anterior inclination vs. standard Lateral inclination vs. standard Posterior inclination vs. standard Tilt of the Tracing Plate Anterior tilt vs. standard Lateral tilt vs. standard Posterior tilt vs. standard Pressure Deliberate pressure vs. minimum pressure 1% Signicance, CR = 2.56 CR = 5.45 CR = 8.12 CR = 7.72 CR = 5.23 CR = 5.34 CR = 5.47 CR = 5.40 CR = 5.44 CR = 5.52 CR = 6.28

difference was shown when the moderately hard and hard wax were compared. There was signicant difference between records when soft wax was pooled on both sides rather than when it was slightly warmed on one or both sides. The soft wax procedure showed the least variation when the occlusal contact was small and limited to the bicuspid and molar regions on each side, together with a small amount of freedom in the anterior region. Variation between records increased when contact existed over the entire ridge in soft wax, and also when there was posterior contact without anterior freedom.

VERTICAL DISCREPANCIES IN WAX RECORDING PROCEDURES

Fig. 3 is a bar graph illustrating the percentage of the records made with wax under different experimental conditions that showed a vertical change at one or more legs of the instrument. The control soft wax recording procedure showed the least amount of vertical discrepancies (17 per cent); whereas the moderately hard and hard wax showed vertical discrepancies amounting to 27 per cent and 40 per cent, respectively. When the recording material was softened but slightly or un-evenly, the percentage of change was 37 per cent and 23 per cent. This indicated that the vertical equalized relationship18 was greatly inuenced by the degree of softening of the recording wax. It was also apparent from this gure that the percentage of records showing vertical discrepancies was inuenced by the amount of occlusal contact. Vertical discrepancies were observed in 67 per cent of the records where occlusal contact was made in soft wax over the entire rim; 80 per cent when anterior contact existed on occlusion rims formed of
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hard wax; but, only 17 per cent when the recordings were made in soft wax without anterior contact.

INTRAORAL TRACING PROCEDURES

Standard deviations were computed for each of the variables studied and are presented in a modied bar graph form in Fig. 4. The control mounting procedure showed the least amount of deviation, and the variation between records increased with the introduction of variables. It was apparent that the control intraoral tracing procedure evidenced the least variation, showing standard deviation of 0.4 mm. laterally and 0.11 mm. anteroposteriorly. It was also apparent that the records which showed the greatest variation were obtained when the central bearing point was inclined posteriorly. A statistical evaluation was made to determine if the differences obtained in Fig. 4 were signicant. The means,
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Fig. 6. The bar graphs indicate the percentage of various intraoral tracing procedure registrations that show vertical discrepancies. Fig. 5. Comparison of results of intraoral tracing procedure (standard deviations) obtained with various ridge classications. The central bearing point was placed laterally, anteriorly, and posteriorly from the correct center position. Table V. Critical ratios of types of ridge (at vs. well-developed)
Anterior displacement of central bearing point Posterior displacement of central bearing point Lateral displacement of central bearing point 1% Signicance, CR = 2.56 CR = 0.33 (not sig.) CR = 1.16 (not sig.) CR = 4.86(l% sig.)

standard deviations, and critical ratios were computed and are presented in Table IV. The data indicated that the introduction of any of the variables studied resulted in differences that were signicant above the 1 per cent level, when compared to the control procedure. The inuence of the location of central bearing point was studied in subjects with different types of ridges: at and well-developed. The results of 5 subjects in each group are presented in Fig. 5. The group with at ridges showed slightly more variation than did the subjects with well-developed ridges. The statistical values are presented in Table V. The laterally displaced central bearing point resulted in greater variability in patients with at type ridges than in those with well-developed ridges. This difference was statistically signicant to the 1 per cent level, whereas no signicant difference could be demonstrated in the anterior or posterior position. Fig. 6 is a bar graph illustrating the percentage of records that show vertical discrepancies. Changes were found in 9 per cent of the registrations made with the
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Fig. 7. The bar graphs indicate a comparison of the percentage of intraoral tracing procedure registrations that show vertical discrepancies for various ridge classications.

control procedures. When the central bearing point was located laterally, anteriorly, or posteriorly, the percentage of records showing vertical discrepancies amounted to 67, 73, and 57 per cent, respectively. Inclination of the central bearing point resulted in changes of 40 per cent (lateral), 40 per cent (anterior), and 20 per cent (posterior). The percentage of records showing vertical discrepancies was 40, 20, and 40 per cent with the lateral, anterior, and posterior tilting of the tracing plate. The percentage of records that showed vertical discrepancies amounted to 57 per cent when the registrations were made under deliberate heavy pressure exerted by the patient. When minimal holding pressure
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was used, none of the 15 records obtained showed detectable vertical discrepancies. Further analyses were made to determine if the type of ridge inuences the percentage of records showing vertical discrepancy. The percentage of registrations showing vertical discrepancies for different locations of the central bearing point in well-developed and at types of ridges are presented in Fig. 7. The anterior placement of the central bearing point in at ridges resulted in vertical discrepancies in all of the records made. The placement of the central bearing point in the lateral and posterior position resulted in vertical discrepancies in 53 and 60 per cent of the records studied. In well-developed ridges, vertical discrepancies of 80, 33, and 46 per cent were shown with lateral, posterior, and anterior placement of the central bearing point.

SUMMARY
A study was conducted on 35 edentulous patients in which two centric relation recording procedures were evaluated to determine the inuence of variables on their duplicability. In the wax recording procedure, the consistency of the recording wax, its degree of hardness, its degree of bilateral homogeneity, the amount of occlusal contact, and the presence or absence of anterior freedom inuenced duplicability to a signicant level. In the intraoral (needle-point) tracing procedure, the location of the central bearing point, anteriorly, posteriorly, or laterally, the inclination of the central bearing point in relation to the tracing plate (whether it be perpendicular or mouted at an angle to it), and the inclination of the tracing plate in relation to the underlying bearing surfaces played an important part in determining the duplicability of the records. Heavy closing pressure adversely inuenced the duplicability of the recordings under these conditions. It is recommended that centric relation records be made with accurately tting baseplates under minimal pressure that is centralized and distributed uniformly to the underlying denture bearing areas (basal seat).
REFERENCES
1. Gysi A. The problem of articulation. D Cosmos 1910;52:1-19. 2. Needles JW. Mandibular movements and articulator design. J Am Dent Assoc 1923;10:927-35. 3. Stansbery CJ. Functional position checkbite technic. J Am Dent Assoc 1929;16:421-40. 4. Schuyler CH. Intra-oral method of establishing maxillomandibular relation. J Am Dent Assoc 1932;19:1012-9. 5. Wright WH. Use of intra-oral jaw relation wax records in completed denture prosthesis. J Am Dent Assoc 1939;26:542-55. 6. Boos RH. Intermaxillary relation established by biting power. J Am Dent Assoc 1940;27:1192-9. 7. Hardy IR. Technic for the use of non-anatomic acrylic posterior teeth. Dent Dig 1942;48:562-6. 8. Pyott JE, Schaeffer A. Simultaneous recording of centric occlusion and vertical dimension. J Am Dent Assoc 1952;44:430-6. 9. Shanahan TEJ. Physiologic jaw relations and occlusion of complete dentures. J Prosthet Dent 1955;5:319-24. 10. Hanau RL. The relation between mechanical and anatomical articulation. J Am Dent Assoc 1923;10:776-84. 11. Hanau RL. Occlusal changes in centric relation. J Am Dent Assoc 1929; 16:1903-15. 12. Gysi A. Practical application of research results in denture construction. J Am Dent Assoc 1929;16:199-223. 13. Trapozzano VR. Occlusal records. J Prosthet Dent 1955;5:325-32. 14. Kingery RH. A review of some of the problems associated with centric relation. J Prosthet Dent 1952;2:307-19. 15. Payne SH. Selective occlusion. J Prosthet Dent 1995;5:301-4. 16. Boucher CO. Errors developed by the use of central bearing point in adjustment of articulators. J Dent Res 1938;17:91-3. 17. Hardy IR. Technic followed in the post-graduate prosthetic department of Tufts University School of Dental Medicine, Boston, Mass. 18. Yurkstas AA, Kapur KK. An evaluation of centric relation records obtained by various techniques. J Prosthet Dent 1957;7:770-86. 19. Garrett HE. Statistics in psychology and education. 4th ed. New York: Longmans, Green; 1953. 0022-3913/$30.00 Copyright 2005 by The Editorial Council of The Journal of Prosthetic Dentistry. doi:10.1016/j.prosdent.2004.10.026

DISCUSSION
The purpose of this study was not to evaluate the accuracy of one recording procedure over another, but to emphasize the fact that there are many variables which can enter into any recording procedure when care is not taken in its execution. In the wax procedures studied, it was shown that the degree of variation could be kept at a minimum, provided equalization of pressure was maintained either through the type of wax used, the execution of uniform softening of the wax, or the amount of contact between the occlusion rims. According to the results of this study, it is not desirable to exert any closing pressure in the anterior region, but to limit the placement of the recording wax to the bearing area of the supporting tissues. In other words the recording medium should be placed only in the bicuspid and molar regions of the residual ridge. The softer the wax, and the more nearly homogeneous both sides were made, the more duplicable the recording procedure became. Hanaus11 and Wrights5 subjective ndings were conrmed in that equalized bilateral pooling of the wax was a paramount factor in securing accurate wax registrations. These data also supported the subjective statement of Trapozzano13 that, correctly used, the wax check bite procedure is an accurate one. In the intraoral tracing procedure, the data seemed to indicate that the duplicability was greatly inuenced by the position of the central bearing point, the inclination of the central bearing point, and the relative tilt of the tracing plate. It was also inuenced by the amount of closing pressure exerted by the patient. In order to insure greatest possible clinical accuracy of a recording procedure, minimal closing pressure must be exerted during its execution, and occlusal forces must be centralized and equally distributed to the underlying structures most suitable for resisting the force used in making the records.

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