HORIZONTAL JAW RELATION

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CONTENTS :-

1. Introduction

2. History

3. Definitions

4. Difficulties in retruding mandible

5. Method of recording centric jaw relation

6. Classification of GATs

7. Reference

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Introduction

It is the relationship of the mandible to the maxilla in a

horizontal plane. It can also be described as the relationship of the

mandible to the maxilla in the anteroposterior direction. Horizontal jaw

relation can be of two types namely centric and eccentric jaw relations.

Centric relation denotes the relationship of the mandible to the

maxilla when the mandible is at its posterior most position. Eccentric

relation denotes the relationship of the mandible to the maxilla when

the mandible is at any position other than the centric relation position.

Centric relation can be described as the most posterior relation

of mandible to the maxilla at the established vertical dimension from

which lateral movements could be made. Any position of the mandible

other than that of the centric relation is called an eccentric position.

Centric relation is the most posterior relation of the mandible to

the maxilla and the antero-superior relation of condyle to the glenoid

fossa.

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History

Balkwill (1866) showed the intersection of the right and left

arches of mandibular movement.

Hesse (1897) first needle point tracing done and introduced the

graphic method of recording centric relation.

Gysi (1910) improved and popularized this method.

Philips (1927) recognized that any lateral movement of the jaw

would cause interference of the rim and could result in a distorted

record. He developed a plate for the upper rim, a tripoidal ball bearing

mounted on a jack screw for the lower rim. This invention was called

central bearing plate (CBP) and claimed to produce equalized pressure

on the edentulous ridges.

Stansberry (1929) introduced a curved plate of a 4  radius

(corresponding to the monsoon curve) mounted on the upper rim.

A central bearing screw was attached to a lower plate with a 3 

radius (reverse monsoon curve). After extra-oral tracings were made

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plaster was injected between the plates to form a biconcave centric

registration.

Harddy and Pleasure described the use of Cobble Balnacer and

later Hardy described a modified intra-oral tracer similar to Cobble.

Hardy and Porter made a depression with a round but at the apex

of the tracing. Patient would hold the bearing point in the depression

while plaster was injected to form the centric record.

Pleasure (1955) used a plastic disc which was attached to the

tracing table with a hole over the apex of the GA.

Definitions

1. “The maxillomandibular relationship in which the condyles

articulate with the thinnest avascular portion of their respective

disks with the complex in the anterior-superior position against

the slopes of the articular eminences. This position is

independent of tooth contact. This position is clinically

discernible when the mandible is directed superior and

anteriorly. It is restricted to a purely rotary movement about the

transverse horizontal axis” (GPT – 5).

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2. “A clinically-determined position of the mandible placing both

condyles into their anterior uppermost position. This can be

determined in patients without pain or derangement in the TMJ”

(Ramsfjord 1993). In dentulous patients the proprioceptive

impulses are obtained from the periodontal ligament.

Edentulous patients do not have any proprioceptive guidance

from their teeth to guide their mandibular movements. The source of

the proprioceptive impulses for an edentulous patient is transferred to

the temporomandibular joint. The centric relation position acts as a

proprioceptive centre to guide the mandibular movements.

The centric relation has the following features:

 It is learnable, repeatable and recordable position which

remains constant throughout life.

 It is a definite learned position from which the mandible can

move to any eccentric position and return back involunrarily. It

acts as a centre from which all movements can be made.

 If the mandible has to move from one eccentric position to

another it should go to the centric relation before advancing to

the target eccentric position.

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  Functional movements like chewing and swallowing are

performed in this position, because it is the most unstrained

position.

 The muscles that act on the temporomandibular joint are

arranged in such a way that it is easy to move the mandible to

the centric position from where all movements can be made.

 The casts should be mounted in centric relation because it is the

point from which all the movements can be made or simulated in

the articulator.

 It is helpful in adjusting condylar guidance in an articulator to

produce balanced occlusion.

 It is definite entity, so it is used as a reference point in

establishing centric occlusion.

Centric relation is a learned position and the dentist should teach

the patient with patience to move his mandible form the centric

relation position.

Retruding the mandible

The mandible should be in its most posterior position while

recording centric relation. Some patients may show difficulties in

retruding the mandible due to certain systemic conditions. These

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difficulties can be overcome by conditioning the patient

psychologically, using special jaw relating apparatus etc.,

Method of retruding the mandible

 Relaxing the patient. Making him feel comfortable.

 The patient is asked to try to bring his upper jaw forward while

occlusing on the posterior teeth.

 The patient should be instructed to touch the posterior border of

the upper record base with his tongue.

 The mandible occlusal rim should be tapped gently with a finger.

This would automatically make the patient to retude his

mandible.

 The temporalis and the masseter are palpated to relax them.

Difficulties in retruding mandible

Difficulties in retruding the mandible can be classified as

 Biological

 Physiological

 Mechanical

Biological causes

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  Lack of coordination between groups of opposing muscles when

the patient is requested to close in the retruded position.

 Habitual eccentric jaw relation.

Physiological causes

Inability of the patient to follow the dentist’s instructions is one

of the major psychophysiological factors, which produce difficulty in

retruding the mandible. This is overcome by instituting stretch relax

exercises, training the patient to open and close his mouth. Central

bearing devices can also be used to retrude the mandible in these

patients.

Mechanical causes

Poorly fitting base plates produce difficulty in reruding the

mandible. The base plates should be checked using a mouth mirror for

proper adaptation.

Methods of recording the centric jaw relation

Physiological methods

 Tactile or inter-occlusal check record method

 Pressureless method

 Pressure method

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Functional method

 Needlehouse method

 Patterson method

Graphic method

 Intraoral

 Extraoral

Radiographic method

Physiologic methods

Physiological methods are called so because they are based on

 The proprioceptive impulses of the patient.

 Kinesthetic sense of mandibular movement.

 The visual acuity and sense of touch of the dentist.

 No pressure is exerted on the interocclusal record.

Tactile sense or inter-occlusalCheck record method

Indications

 Abnormally related jaws.

 Displaceable, flabby tissues.

 Large tongue.

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  Uncontrolled mandibular movments.

 It can also be done for patients already using a complete denture.

Factors affecting the success of inter-occlusal record method

 Uniform consistency of the recording material.

 Accurate vertical jaw relation records.

 Stability and fit of the record base.

 Presence of reference points embedded in the record like metal

pins or styli.

The commonly used materials for making the inter-occlusal

record in this method are waxes, impression compound, ZnOE and

impression plaster.

Procedure

Two steps

Tentative jaw relation

 The maxillary occlusal rim is inserted into the patient’s mouth. A

denture adhesive can be used to improve retention.

 The vertical dimension at rest is established and the mandibular

rim is reduced further for excess inter-occlusal distance.

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  A tentative centric relation is recorded by using one of the

previously mentioned methods to retrude the mandible.

 The occlusal rims are articulated using the tentative jaw

relations and the artificial teeth are arranged.

 Now the trial dentures are ready for making the inter-occlusal

check record.

Making the inter-occlusal check record

 The upper and lower trial dentures are inserted into the patient’s

mouth. The artificial teeth are prevented from contacting the

opposing members by keeping a piece of cotton inter-occlusally.

 Aluwax is loaded on to the occlusal surface of teeth in the

mandibular occlusal rim.

 The patient is asked to slowly retrude the mandible and close on

the wax till tooth contact occurs.

 The trial dentures are removed and the wax is allowed to cool.

 Both the maxillary and mandibular trial dentures are placed on

their articulated casts.

 Before placing the trial dentures, the horizontal condylar guide

locks in the articulator are unlocked to allow free horizontal

movement of the casts.

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  The Aluwax on the buccal aspect of mandibular teeth is scraped

off and the articulated casts (which are free to move

horizontally) are adjusted to fit into the Aluwax check record.

 If the tentative relation record is accurate and is the same as the

check record then both the condylar elements of the articulator

will contact against the centric stops i.e. the articulated casts

need not move to fit into the check records.

 If anyone of the condylar elements (condylar element represents

the condyle in the articulator) do not contact on the centric stops

(centric stop represents the centric position of the condyle in the

glenoid fossa) it indicates that the tentative recording is

inaccurate.

 Occlusal indicator wax can be used instead of Aluwax for

recording trial dentures with non-anatomical (cuspless) teeth.

Static or pressureless method

The occlusal rims are customized as usual and the patient is

trained to close at centric relation position. Once the patient attains the

centric relation position, the denture bases with occlusal rims are

sealed in this position. The nick and notch method or the stapler pin

method can be used to index/seal the occlusal rims.

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Pressure method

Here, after establishing the vertical dimension, the upper

occlusal rim is inserted into the patient’s mouth. The lower occlusal

rim if fabricated to be of excess height. The entire loser occlusal rim is

softened in a water bath and inserted carefully into the patient’s mouth.

The patient is guided to close his mouth in centric relation. The

dentist should gently guide the mandible. The patient is asked to close

on the soft wax. After the patient closes his mouth till the

predetermined vertical dimension, both the occlusal rims are removed,

cooled and articulated.

Functional method or Chew-in method

These methods utilize the functional movements of the jaws to

record the centric relation. The patient is asked to perform border

movements such as protrusive and lateral excursive movements in

order to identify the most retruded position of the mandible.

The following factors are common to all functional methods:

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  In a functional method, a tentative centric relation and vertical

dimension are measured for determining an accurate centric

relation.

 The occlusal rims for these methods are reduced in excess than

that required for the tentative vertical dimension.

 The exact vertical dimension of occlusion is determined only

when the patient closes on the occlusal rims and their

attachments (tracers etc).

 The record bases should be very stable while recording centric

jaw relation. If the record base gets displaced, the mandible will

tend to move into an eccentric position.

 Lack of equalized pressure exerted on the record base can result

in inaccuracies in recording centric jaw relation.

 A good neuromuscular coordination is required form the patient.

Needlehouse method

This is one of the most commonly used functional techniques.

 It involves the fabrication of occlusal rims made from

impression compound.

 Four metal beads or styli are embedded into the premolar and

molar areas of the maxillary occlusal rim.

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  The occlusal rims are inserted into the patient’s mouth and all

the above-mentioned factors affecting functional centric relation

are considered.

 The patient is asked to close on the occlusal rims and make

protrusive, retrusive, right and left lateral movements of the

mandible.

 When the patient moves his mandible, the metal styli on the

maxillary occlusal rim will create a marking on the mandibular

occlusal rim. When all the movements are made, a diamond-

shaped marking pattern rather than a line is formed on the

mandibular occlusal rim.

 The posterior most point of this diamond pattern indicates the

centric jaw relation.

Patterson’s method

 Here occlusal rims made of modeling wax are used.

 A trench or trough is made along the length of the mandibular

occlusal rim.

 A 1:1 mixture of carborundum and dental plaster is loaded into

the trench.

 The occlusal rims are inserted and the patient is asked to

perform mandibular movements.

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  These movements will produce compensating curves on the

plaster carborundum mix.

 As these movements are made, the height of the plaster

carborundum mix is also reduced.

 The patient is asked to continue these movements till a

predetermined vertical dimension is obtained.

 Finally the patient is asked to retrude his jaw and the occlusal

rims are fixed in this position with metal staples.

Graphic methods

These methods are called so because they use graphs or tracings

to record the centric jaw relation. Graphic methods are of two types

namely arrow point tracing and the pantograph.

Factors to be considered while carrying out tracing procedures

These factors may affect the accuracy of graphic tracing.

Precautions should be taken in relation to these factors to avoid any

errors in tracing.

 Stability of the denture base.

 Resistance offered by the occlusal rims against occlusal forces.

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  Difficulty in placing the central-bearing device in protruded and

retruded jaws.

 Presence of flabby tissue and its effect on the denture base.

 Height of the residual alveolar ridge influencing the stability of

the record base.

 Interference from the tongue.

 Efficiency of the recording devices during physiological

mandibular movements.

 Obtaining a pointed apex in the tracing pattern (All tracing

patterns will have an apex which is a single point from where all

patterns appear to arise from).

 Lack of coordinated movement. This can cause double tracing.

 The graphic tracing should harmonize with the centric relation,

centric occlusion, bone-to-bone relation and tooth-to-tooth

contact.

Intra-oral Vs Extra-oral

Intra-oral Extra-oral

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01. Tracing not visible when being made Visible when the tracing is being made

02. Tracings are small as they are located Larger tracings easier to locate the
close to the centre of rotation. apex.
Therefore difficult to locate the apex.

03. More accurate than extra oral as it is

made closer to the center of rotation Less accurate than intra oral as made
of the condyle. further away from the center of
rotation.
04. Plate and styles not hindered by the
position of lips and cheeks.
The lips and cheek interfere with the
05. Lips and cheeks in passive relation. position of the plate and the styles.

Does not keep the lips and cheek in

06. Accuracy of the record cannot be passive relation.
assessed as the record bases may shift
during the recording. Accuracy can be assessed virtually.

07. Example:
Seidal tracer
Ballard tracer Example:
Messermar tracer Hight tracing device
Cobble tracer Stansberry tracers
Philips extra-oral tracer
Sears trivet

The primary and most important component of an intra-oral or extra-

oral tracer is a central bearing device.

The central bearing device

 Put forward by Stansberry

 Consists of central bearing support/contact between the

maxillary and mandibular arches.

 It has a styli or a point attached to the upper record base.

 It has a central bearing plate attached to the lower occlusal rim.

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  The stylus / point and the plate should be perpendicular to each

other.

 The stylus and plate should be placed at the geometric center of

the arches so that the mandibular movements are dictated by the

condyles and not the central bearing device.

Functions of central bearing device

 Maintains VD

 Equalizes the pressure by distributing the forces throughout the

supporting tissues.

 Allows the mandibular movement to be dictated by the condyles.

Indications of graphic method

 Well healed broad edentulous sides.

 Adequate inter arch space

 In patients with habitual centric; the use of the graphic method

eliminates all occlusal contacts on the occlusal rims, thus

breaking the neuromuscular engram and allowing the patient to

record his true centric.

Contraindications

 Severely resorbed ridges.

 Excessively flabby ridges.

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 The above two are unstability of the record bases.

 Decreased arch space  difficult to place central bearing device

without raising the VD.

 In patient with temporomandibular joint arthropathy.

 In patient with abnormal jaw relations.

Classification of GAT’s

 Putforth by Gerber 1966

Typical form

It has a well defined apex with a normal right and left

component. It indicates a healthy temporo-mandibular joint, with no

interference in condylar movements and a balanced muscle guidance.

Gothic arch angle is 120 0 .

Flat form

It is similar to typical form on the right and left lateral tracings

are more obtuse or flat. This indicated a marked lateral movement of

the condyles in the fossa. Angle is more than 120 0 .

Asymmetrical

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 It has normal right and left components. But the protrusive path

is deviated to one side or one arm is shorter. It indicates inhibition of

forward movement either in left or right joint.

Apex absent/round

It indicates a weak retrusive movement. It requires repeated

tracing till a definite arrow point is obtained. Patient training is

necessary.

Miniature

Arrow point is similar to typical but shorter in size. Due to

 Restricted mandibular movements.

 Improper seating of record bases.

 Long period of edentulousness with an inhibition in condylar

movements.

Double arrow point

 Indicates a habitual and retruded centric relation.

 It also indicates an alteration in the VD during tracing.

 Train the patient.

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  Correct the VD (by using the central bearing device).

Dorsally extended arrow point

 The protrusive path extends beyond the apex.

 Seen in patients with a forced strained retrusive movement of the

lower jaw by patients or operator.

 An antifact created while removing the upper or lower occlusal

rims from the mouth. Upper  backward displacement; lower 

forward displacement.

 It can also occur if patient head is tilted too far posteriorily.

Gerber felt that the distal extension was correct, but the tracing

was obtained in a protrusive relation.

Interrupted Gothic arch

 Break or loss of continuity of the incisal path.

 Due to posterior interference at the heels during movements.

Atypical form

 Protrusive component does not meet at the apex but on one of the

lateral paths.

 Occurs in prolonged edentulisum.

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  Patient has been wearing dentures with incorrect centric relation.

Factors to be kept in mind during GAT

 Displacement of the record bases may result from pressure if the

CBP is off centre when the mandible moves into an eccentric

relation.

 If central bearing device used then the occlusal rims differ more

resistance to movement.

 It is difficult to locate the centre of the arches to centralize the

forces when the jaws are favorable let alone in an abnormal

relation.

 Difficult to stabilize record bases when the tissues are

pendulons, flabby and easily displaceable.

 Difficult to stabilize a record base against horizontal forces on

greatly resorbed ridges.

 Difficult to stabilize a record base with a large awkward tongue.

 GAT is made at a predetermined VD of occlusion.

 Tracing is not accepted unless proper pointed apex is obtained.

 Graphic records can record eccentric relation of mandible to

maxilla.

 Graphic methods are the most accurate means of making a

centric relation recording with a mechanical instrument.

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Pantographic tracing

It is defined as, “A graphic record of mandibular movement in

three planes as registered by the styli on the recording tables of a

pantograph; tracings of mandibular movements recorded on plates in

the horizontal and sagittal planes” – GPT.

It is a three-dimensional graphic tracer. It is the most accurate

method available to record centric jaw relation. Even eccentric jaw

relation can be recorded using these instruments. These equipments are

very sophisticated and are generally not used in the fabrication of

complete dentures. This is because complete dentures have a realiff

factor that aids to compensate for the minor fabrication errors. These

tracers are generally used for full-mouth rehabilitation of dentulous

patients.

The instrument used to do a pantographic tracing is called a

pantographic tracer. A pantographic tracer is defined as, “An

instrument used to graphically record one or more planes paths of the

mandibular movement and to provide information for the programming

of the articulator” – GPT.

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 A pantographic tracer has six flags:

 Two flags located perpendicular to one another near the

condyles. Totally there are four flags adjacent to the right and

left condylar guidances. They locate the actural (true) hinge

axis.

 Two flags are placed in the anterior region. They record the

anteroposterior movements.

Other methods of recording centric-jaw relation

Other methods of recording centric jaw relation include:

 Making the rims contact fairly and evenly in the mouth at the

desired vertical relationship. This usually makes the mandible

close at centric relation.

 Strips of celluloid (or) paper are placed between the rims and

pulled out. The patient is asked close and restrains the celluloid

from slipping away. While doing so the patient’s mandible

involuntarily goes to centric relation.

 Softened wax may be placed on the mandibular oclusal rim and

the patient is asked to bite in centric relation.

 Conical blocks of wax can be made on the mandibular record

base and the patient is asked to close on them at centric relation.

Eccentric jaw relation

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 Eccentric jaw relations is defined as, “Any relationship of the

mandible to the maxilla other than the centric relation” – GPT.

It includes protrusive and lateral relations. The main reason in

making an eccentric jaw relation record is to adjust the horizontal and

lateral condylar inclinations in the articulator. This helps the

articulator to reproduce eccentric movemnts of the mandible and

establish balanced occlusion. Eccentric relations can be recorded using

functional or tactile methods. Methods of recording eccentric jaw

relation are similar to the ones used to record centric relation position.

Factors to be considered while making eccentric jaw relations

 The condylar path cannot be altered.

 The condyles do not travel in straight lines during eccentric jaw

movements.

 Semi-adjustable articulators in which the condyles travel on a

flat path cannot be used to reproduce eccentric movements.

 Most complete denture articulators do not support lateral

records.

 Fully adjustable articulators where the condylar and incisal

guidances are fabricated individually with acrylic can travel in

the path of the condyle using pantographic tracings.

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References

1. John J. Sharry: complete denture prosthodontics. Third Edition,

A Blakstion Publication; 215-220

2. Charles M. Heartwell. Jr., Arthur O. Rahn: Syllabus of complete

denture. Fourth Edition; 1992; 225-228

3. George A. Zarb, Charles L. Bolender: Boucher ’s Prosthodontic

treatment for Edentulous Patients. Tenth Edition, B.I

Publications Pvt. Ltd; 1990; 285-295

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