Download Academic paper: Distance between the Retruded Contact Position

Nohre- Solvang A et al
J Pak Prosthodont Assoc 2015; 03(01): 4– 10
Distance between the Retruded Contact Position and the Maximal Intercuspal
Position in Young Adults*
Anne Nohre-Solvang
Anne-Mari Skarsvåg
Morten Berge
Anders Johansson
Gunnar E Carlsson
DDS1
DDS1
DDS, PhD1
DDS, PhD1
DDS, PhD, Dr Odont hc, Dr Dent hc, FDSRCS (Eng)2
1
Department of Clinical Dentistry – Prosthodontics, Faculty of Medicine & Dentistry, University of Bergen, Bergen,
Norway.
2
Department of Prosthetic Dentistry/Dental Materials Science, The Sahlgrenska Academy, University of Gothenburg,
Göteborg, Sweden
Correspondence: Gunnar E Carlsson, Department of Prosthetic Dentistry/Dental Materials Science, Institute of
Odontology, The Sahlgrenska Academy, University of Gothenburg, Box 450, SE 405 30 Göteborg,
Sweden. Tel.: +46 31 786 3191; fax.: +46 31 786 3193, e-mail:[email protected]
*N.B:
Presented by the corresponding author as an oral report at the 29 th Conference of the Society of Oral
Physiology 28–31 May, 2015, Innsbruck, Austria.
Abstract
Purpose: The relationship between retruded contact position (RCP) and maximal intercuspal
position (MIP) has received considerable interest in dental literature, but there are still unanswered
questions. The aims were to establish a method for accurate measurement of the distance between
RCP and MIP in a group of healthy young adults and to analyse the relationship between RCP-MIP
distances and some other variables.
Methods: Recording of RCP was performed in 79 healthy subjects (56 women, 23 men), aged 20 –
30 years, using both operator and patient guidance of the mandible. Horizontal and vertical
distances between these positions and MIP as well as overjet and overbite were measured with a
precision apparatus.
Results: Measurement error was small. There were significant differences between positions
recorded with operator and patient guidance; RCP was on average 0.24 mm more posterior with
operator than with patient guidance. Mean overjet and overbite were 3.42 mm and 2.85 mm,
respectively. Means of the horizontal and vertical operator-guided RCP-MIP distance were 0.84 and
0.72 mm, respectively; the range was 0 to 2.5 mm. There were no significant differences for
horizontal RCP–MIP distance between subjects with Angle Classes I and II, nor between those with
and without previous orthodontic treatment. There was no sex difference for means of the
measurements.
Conclusions: Operator-guided RCP resulted in a more posterior mandibular position than patientguided RCP. The RCP–MIP distances varied between 0 and 2.5 mm. The horizontal RCP–MIP distance
was not significantly associated with height, sex or overjet, nor did it differ between subjects with
Angle Class I or II.
Key words: Centric slide, Mandibular positions, Operator guidance, Overbite, Overjet.
How to cite this article: Nohre-Solvang A, Skarsvåg AM, Berge M, Johansson A, Carlsson GE.
Distance between the retruded contact position and the maximal intercuspal position in young
adults. J Pak Prosthodont Assoc 2015; 03 (01): 04 – 10.
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Nohre- Solvang A et al
J Pak Prosthodont Assoc 2015; 03(01): 4– 10
Introduction
The retruded contact position (RCP), or centric
relation (CR), and the maximal intercuspal position
(MIP) are important mandibular positions in
prosthodontic diagnosis and therapy.1-3 The
distance between RCP and MIP, called centric slide
as a movement between the positions ,1 has
received considerable interest in the dental
literature over the years.4-6 It has been suggested
that the distance might be related to the health of
the masticatory system and, when increased or
when the slide is asymmetric, being possible
etiologic factors for temporomandibular disorders
(TMD).7-12
overbite, body height, Angle Class, and previous
orthodontic treatment. It was hypothesized that
the horizontal RCP–MIP-distance would be smaller
in the examined group of young adults with good
dental health than in earlier studies with greater
variation in the dental situation.
Materials and methods
Subjects
Participants in the study were selected among the
159 students in the later part of the undergraduate
dental and dental hygienist programs at the
University of Bergen, Norway. During the period of
the investigation 79 (56 women, 23 men) of them
were available and fulfilled the inclusion criteria
(age 20-30 years, Class I or II Angle Classification;
Class III was excluded). All the participants had a
full complement of natural teeth (except for single
teeth extracted for orthodontic reasons) and they
had no manifest signs and symptoms indicating
TMD. On 13 randomly selected participants the
measurements were repeated after one week for
an analysis of the measurement error.
In one of the first studies on the relationship
between RCP and MIP, Posselt13, using a
cephalometric technique, found that 88 % had a
centric slide (mean horizontally 1.25, SD 1.0;
vertically 0.90, SD 0.75 mm), whereas in 12 % the
positions coincided. A wide range of results has
been reported in later studies, probably due to
both differences between methods used and the
great individual variation between participants in
the studies.10-18 In textbooks on prosthodontics and
occlusion it has been stated that most individuals
will adapt well to a distance between RCP and MIP
of 0.3 to 0.8 mm19 or up to 1mm.2, 20 The basis for
these statements has in general not been
presented, which was one of the factors that
initiated the present study. Another factor of
interest was the great variation of the published
results and that the majority of the previous
studies were performed more than two decades
ago. It can be speculated that the improved dental
health in young adults today may have an influence
on the relationship between RCP and MIP. Already
three decades ago studies showed that there were
on average more signs and symptoms of
temporomandibular dysfunction (TMD) and larger
distance between RCP and MIP in adolescents with
restored compared to intact dentitions.17, 21
Recording of mandibular positions
When recording MIP the patient, sitting upright in
a dental chair, was told to relax and bite together /
close the teeth in a normal way. An operator
checked that the jaws were in maximal
intercuspation. Recording of the operator-guided
RCP was performed with the patient relaxed in a
slightly reclined position and with chin-point
guidance.22 When recording the patient-guided
RCP, the patient was also slightly reclined, told to
relax and move the mandible as far backwards as
possible and then bring the teeth together and
stop at the first contact. This recording was
performed without operator guidance.
Measurements
Measurements were made clinically by two
operators with a precision apparatus, vernier
calliper, recording thousandths of mm (Mitotoyo
Digimatic model NTD 12-15; Mitutoyo Corporation,
Tokyo, Japan) (Figure 1). In the recording of the
measurements the results were rounded off to two
decimals. The most prominent central incisor (11
or 21) was marked with Indian ink (Staedtler
permanent Lumocolor dim. 0.7 mm waterproof,
Nuernberg, Germany). A vertical line was marked
The objectives of the study were: 1) to establish a
method for accurate measurement of the distance
between RCP and MIP; 2) to use the method for
measurement of this distance in a group of healthy
young adults after recording RCP with an operatorguided and a patient-guided method; 3) to analyse
the relationship between RCP–MIP-distance and
the variables horizontal overjet and vertical
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Nohre- Solvang A et al
J Pak Prosthodont Assoc 2015; 03(01): 4– 10
ca 2mm from the meso-incisal corner to make all
measurements at the same point (Figure 2 A).
above. The same measurement procedure was
used for the operator- and patient-guided RCP.
Figure 3. Schematic illustration of measurements
performed.
Figure 1: Vernier calliper (Mitotoyo Digimatic model
NTD 12-15) used in the study.
Calibration of investigators/operators
After having tested to measure a few individuals it
was found that the measurements became more
efficient and more accurate if each operator had a
specific task in the procedure. Such a distribution
of tasks was then followed during the study and
two operators worked together in the recording
procedures.
Figure 2 (a-c): Clinical view of the marking (a, b) &
measurement (c) of vertical overbite.
Measurement of the horizontal overjet
This recording was performed with the patient
sitting in an upright position with the jaws in MIP.
The apparatus was held parallel with the occlusal
and sagittal planes. The stable part of the
measurement pin was set to the mark on the
maxillary incisor and the movable part on the
opposite mandibular tooth. Two measurements
were done in MIP, as well as in both operator
guided and patient guided RCP. If the
measurements differed > 0.2 mm a third
measurement was performed to eliminate a
possible measurement error. The mean of the two
closest results was used in the analyses, rounded
off to two decimals. Measurements of the
horizontal overjet in the operator- and patientguided RCP were done in the same way but the
patient was reclined as described above.
Statistics
Standard statistical methods were used and
computed using IBM SPSS, version 21 (Armonk, NY,
IBM Corp., USA).
Results
Measurement error
The analysis, based on registrations on 13
individuals repeated one week apart showed that
the differences between the first and second
measurement were small for all 6 variables:
horizontal overjet and vertical overbite in MIP, in
the two RCP positions, operator-guided and
patient-guided (Table 1). The means of the
differences varied between 0.02 to 0.10 mm (SD
0.10 to 0.30); the intra-class correlation
coefficients (ICC), were 0.97 to 0.99, i.e. indicating
an almost perfect association between the double
measurements on the same individual.
Measurement of the vertical overbite
In MIP a horizontal line was drawn on the
mandibular incisor opposing the most prominent
maxillary central incisor by means of a thin ruler
held parallel with the occlusal plane. With a
calliper the distance between the upper limitation
of the ink line to the incisal edge was captured and
measured by the measurement apparatus (Figure 2
a and c). A schematic illustration of the
measurements is shown in Figure 3.
The
measurement was repeated and the mean was
used. If the measurements differed > 0.2 mm a
third measurement was performed as described
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Nohre- Solvang A et al
J Pak Prosthodont Assoc 2015; 03(01): 4– 10
Table 1: Analyses of the measurement error based
on repeated registrations of overjet and overbite
one week apart on 13 subjects.
Diff
SD
tau
ICC
HOMIP
0.02
0.27
0.19
0.98
HORCP/OG
0.03
0.27
0.19
0.97
HORCP/PG
0.07
0.30
0.22
0.98
VOMIP
0.10
0.20
0.14
0.99
VORCP/OG
0.08
0.25
0.17
0.98
VORCP/PG
0.02
0.10
0.07
0.99
Diff = Difference between first and repeated
measurement (mm); HO = horizontal overjet;
VO = vertical overbite; OG = operator-guided;
PG = patient-guided; MIP = maximal intercuspal
position;
RCP = retruded contact position
The vertical RCP-MIP distance also differed
between measurements made in the operator- and
patient-guided RCP (0.06 mm; P< 0.01; Table 3).
Table 3: Means (mm) of horizontal and vertical
distance
RCP–MIP in 56 female and 23 male young adults.
Female Male Total SD
Range
HORCP/OG – 0.80
0.94 0.84 0.56 0-2.2
HOMIP
HORCP/PG – 0.59
0.64 0.60 0.50 0-2.0
HOMIP
VORCP/OG – 0.77
0.61 0.72 0.49 0-2.5
VOMIP
VORCP/PG–
0.69
0.60 0.66 0.49 0-1.9
VOMIP
HO = horizontal overjet; VO = vertical overbite;
OG = operator-guided; PG = patient-guided;
MIP = maximal intercuspal position; RCP = retruded
contact position
The distribution of the size of both the horizontal
and vertical RCP–MIP distances showed a wide
variation, with values ranging from 0 to 2.5 mm
(Table 3).Values close to 0 were recorded for 11 %,
whereas approximately 15 % had a horizontal RCP–
MIP distance of > 1.5 mm (Figure 4).
Overjet and overbite
For the whole sample the mean of the horizontal
overjet was 3.42 mm (SD 0.94); the mean of the
vertical overbite was 2.85 mm (SD 1.24; Table 2).
Women had slightly higher values for all 6 variables
but there was no significant difference between
the sexes for any of the measurements (P varied
between 0.15 and 0.71). The horizontal overjet
measured in the operator-guided RCP was greater
than that measured in the patient-guided RCP
(HORCP/OG – HORCP/PG = 0.21 mm; P< 0.001). The
vertical overbite measured in the operator-guided
RCP was smaller than that measured in the patientguided RCP (VORCP/OG – VORCP/PG = - 0.09 mm; P =
0.008).
Table 2: Means (mm) of overjet & overbite in 56
female and 23 male young adults.
Female Male Total SD
HOMIP
3.50
3.23 3.42 0.94
HORCP/OG 4.30
4.17 4.26 1.12
HORCP/PG 4.09
3.87 3.99 1.03
VOMIP
2.98
2.54 2.85 1.24
VORCP/OG 2.21
1.93 2.14 1.19
VORCP/PG 2.30
1.93 2.19 1.16
HO = horizontal overjet; VO = vertical overbite;
OG = operator-guided; PG = patient-guided;
MIP = maximal intercuspal position;
RCP = retruded contact position
Figure 4: Distribution of the horizontal & vertical
distances between RCP & MIP after operator
guidance in 79 young adults.
Association between the RCP – MIP distance and
other variables
Subjects who had received orthodontic treatment
had a smaller vertical distance between RCP and
MIP than those without such treatment. However,
it was statistically significant (P< 0.05) only for the
patient-guided RCP position. For the horizontal RCP
– MIP distance there were no significant
differences between those with and without
orthodontic treatment.
Distance between RCP and MIP / Centric slide
The horizontal distance between RCP and MIP was
greater for the operator-guided than for the
patient-guided RCP (0.24 mm; P< 0.01; Table 3).
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J Pak Prosthodont Assoc 2015; 03(01): 4– 10
There were no significant differences for the RCP–
MIP distances between subjects with Angle Classes
I and II (the great majority had Angle Class I, only 6
subjects = 8 % were Class II).
The mean body height was 181.4 cm for the men
and 167.5 cm for the women. There were no
significant
correlations
between
RCP–MIP
distances and height (Pearson r varied from 0.01 to
0.10).
if necessary more measurements were performed
until the difference between two values was < 0.2
mm.
The analysis of the measurement error using
double registrations on 13 individuals one week
apart showed that the precision of the
measurements was high with ICC values ≥ 0.97.
The mean values of the measurements on the
subjects in the error analyses were very similar to
the results in the whole sample, which also
suggests high reliability of the method used.
There were no significant correlations between the
horizontal overjet and the horizontal and vertical
RCP-MIP distances (r = 0.04 and 0.09), whereas
there was a weak but significant correlation
between the vertical overbite and the horizontal
and vertical RCP–MIP distances (r = 0.23 and 0.29,
respectively; P< 0.05). Overjet and overbite were
weakly correlated with patient-guided RCP (r =
0.26; P = 0.02) whereas the correlation did not
reach significance for operator-guided RCP (r =
0.19; P = 0.10).
Since the usually small or non-existing lateral
movements between RCP and MIP were not
measured, the true 3-dimensional slide could not
be established, only the 2-dimensional horizontal
and vertical distances between the positions. This
limitation of methods used is present in most
previous studies.
Results
The operator-guided retrusion resulted in a more
posterior position of the mandible than the
patient-guided RCP. This was also shown in a
previous study, which found a substantially
reduced reproducibility for the latter method,
called active retrusion, compared to the chin-point
guidance.23 These results have been taken as
support for a recommendation that RCP is best
recorded with operator guidance.22In the present
study the precision of the recordings with the two
methods was similar. In a recent study comparing
two methods to locate centric relation, there were
no significant differences between a method using
leaf gauge without mandibular manipulation to
locate the centric relation position and chin-point
guidance.24 The author concluded in his thesis,
“this outcome confirms the contemporary opinion
in the literature that the method to locate centric
relation is not decisive”, at least in healthy
individuals.6
Discussion
Terminology
We have used the term retruded contact position
(RCP) instead of centric relation (CR) since RCP has
dominated in the Scandinavian literature on
occlusion from Posselt’s studies in the 1950s up to
today.3,13 It has been debated if RCP and CR are
identical even if already Ramfjord and Ash
discussed the terms as synonyms.4 The Glossary of
Prosthodontic Terms1 gives 7 definitions of CR,
which is confusing and has further motivated the
use of RCP instead of CR in Scandinavia.2,3,20 It has
been suggested that RCP “may be more retruded
than the centric relation position”.1 This may be
true but is probably not clinically important, as
possible clinical consequences of such a difference
have not been documented.2
Method error
There were many possible sources of error in the
measurements, such as placement of the
measuring device, reading of the result on the
display, the thickness of the Indian ink mark on the
teeth, stress and muscle tension in the investigated
subjects, etc. However, they were kept under
control as much as possible by following a careful
and standardised technique and collaboration of
the two operators during the procedure. If the
double measurements differed > 0.2 mm a third or
The present study demonstrated a relatively large
variation of the RCP-MIP distance, 0 to 2.22 mm
horizontally (mean 0.84 mm), and 0 to 2.50 mm
vertically (mean 0.72 mm). When distributing the
participants with respect to the magnitude of the
distance, those with a distance of > 0.2 to 0.8 mm
became the largest group, both horizontally and
vertically (Figure 2). A horizontal RCP-MIP distance
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Nohre- Solvang A et al
J Pak Prosthodont Assoc 2015; 03(01): 4– 10
of > 1.5 mm was found in 15 % of the examined
subjects. Varying results have been reported in
other studies, partly due to differences between
measurement methods. Using a cephalometric
method on 50 young adults mean distances of 1.25
mm horizontally and 0.90 mm vertically were
reported.13 In a clinical study of 402 7-15-year-old
children the sagittal distance was 0.6 – 0.7 mm in
the different age groups and 0.3 mm vertically,
measured with a ruler intra-orally. The range was
large: from 0 to > 2.5 mm both horizontally and
vertically (5 children, 1 %, had a sagittal distance of
≥ 2.5 mm).16 In contrast to these results exhibiting
a wide variation of the RCP-MIP distance, a study
on 15 young adults reported a mean of 0.2 mm and
a variation of 0 to 0.4 mm, leading the authors to
conclude that MIP and RCP “are virtually
coincident”.18 This result contrasts to all other
studies but may be a reminiscence of the authors’
preference for now abandoned gnathological
concepts advocating a coincidence of RCP and MIP
in restorative dentistry. The rate of coincidence of
RCP and MIP varies among the studies. Posselt13
reported 12 % and emphasised that the great
majority of individuals exhibited a distance
between the positions. The present results are
similar to those of Posselt: 11 % had a distance
close to 0 (Figure 2). A study using a millimetre
ruler reported a higher prevalence of coincidence:
one third of 739 university students “had no easily
observable shift from RCP to ICP”, whereas 9 % had
a shift greater than 1 mm.15Similar results were
reported in another study on young adults: 29 %
coincidence of RCP and ICP, and 10 % a distance of
≥ 1 mm between the positions.8 The hypothesis at
the planning stage of the study that the improved
dental health in today’s young adults would result
in shorter RCP–MIP distances and an increased
prevalence of coincidence of the two positions
than previous studies reported was not verified.
was of no aetiological importance for TMD. This
has also been demonstrated in previous studies
regarding the sagittal distance.25-27The present
study also supports these results as all participants
were without manifest signs and symptoms of TMD
but had a large range of horizontal and vertical
RCP-MIP distances. However, in one study27 a
significant correlation was found between the
lateral deviation ≥ 0.5 mm between RCP and MIP,
called lateral forced bite, and signs and symptoms
of TMD in young adults. An association between a
lateral shift of > 1 mm from RCP to MIP and
dysfunctional signs was also found in a large study
on young adults.15 These findings might be of
interest to study further, although the dominating
opinion at present is that occlusal factors have no
or at most minor influence on TMD aetiology.28,29
Both RCP and MIP are important positions in
clinical dentistry. The great majority of fixed
prosthodontic restorations are single crowns and
small FDPs, which should be fitted into the existing
occlusion after recording of MIP. RCP is mainly a
reference position for the examination of the RCPMIP relation, and it may be used in extensive
reorganisation of the occlusion and in fabrication
of complete dentures.3
Conclusions
In this study on 79 young adults the operatorguided RCP resulted in a more posterior
mandibular position than the patient-guided RCP
(mean 0.24 mm). The horizontal and vertical RCPMIP distances after operator guidance were on
average 0.84 mm (SD 0.56) and 0.72 mm (SD 0.49),
respectively. The individual distances varied
between 0 and 2.5 mm; there was no sex
difference for any of the measurements. The
horizontal RCP-MIP distance was not significantly
associated with overjet, sex or height, nor did it
differ between subjects with Angle Class I or II.
A recent study on 110 subjects, using a
sophisticated measuring technique, found a large
range of the centric slide (calculated according to
Pythagoras as the hypotenuse of the horizontal
and vertical distances) from 0 to 5.32 mm.12 This
study is also of interest as it included a comparison
between 3 groups of TMD patients and a healthy
control group: there were no significant differences
of the RCP-MIP distance between the groups,
suggesting that the size of the RCP-MIP distance
Conflict of interest statement
The authors report no conflicts of interest. The
authors alone are responsible for the content and
writing of the paper.
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15. Solberg WK, WooMW, Houston JB. Prevalence of
mandibular dysfunction in young adults. J Am Dent
Assoc 1979;98:25–34.
16. Egermark- Eriksson I. Mandibular dysfunction in
children and in individuals with dual bite. Swed
Dent J, 1982, Suppl 10:1–45.
17. Kampe T, Hannerz H. Differences in occlusion and
some functional variables in adolescents with
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Acta Odontol Scand 1987;45:31–9.
18. Wilson J, Nairn RI. Occlusal contacs in mandibular
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19. Ash MM, Ramfjord SP. Occlusion. 4th ed.
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20. Molin Thorén M, Gunne J (Eds). Textbook of
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23. Helkimo M, Ingervall B, Carlsson GE. Comparison of
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24. Zonnenberg AJJ, Mulder J. Reproducibility of 2
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