Centric relation and condylar movement:

Anatomic mechanism

P. Saizar, D.D.S.*
University of Buenos Aires, Dental School, Buenos Aires, Argentina

lh e anatomic mechanism responsible for centric relation is unknown, and there-

fore several different theories have been developed. The three most generally ac-
cepted are (1) the muscle theory, (2) the ligament theory, and (3) the osteofiber
theory. A fourth one, the meniscus theory, is presented in this article.

THE MUSCLE THEORY

The muscle (or myologic) theory considers centric relation to be the product
of a defense reflex which causes the external pterygoid muscles to contract, and thus
to halt the jaw every time the condyles or the interarticular discs approach the
posterosuperior depths of the glenoid fossae.
The muscle theory, however, offers no satisfactory explanation for some aspects
of centric relation. It does not explain the fact that centric relation is always the
same at any vertical level, nor does it explain the most posterior mandibular posi-
tion. Furthermore, no anatomic explanation is provided for the posterior hinge
movement, nor for the acuteness of the “needle-point” tracing. If the external
pterygoid muscles were responsible for centric relation, the hinge axis would then
go through the anterior cervical insertion of these muscles, which it does not do, and
the “needle-point” tracing would be elliptical. This explains why Woelfel, Hickey,
and Rinearl found that the external pterygoid muscles are relaxed when the man-
dible is in centric relation.
The muscle theory is not correct, even though it is supported by an existing neuro-
muscular mechanism. The external pterygoid muscles halt the jaws in practically all
positions except centric relation. When these muscles halt the jaws in eccentric
positions, mandibular hinge movements may develop which coincide neither with
the posterior hinge movement nor with centric relation.

THE LIGAMENT THEORY

FerreirP was the first to present the ligament theory. After he had located the
temporomandibular ligaments, he felt that when they become tense they determine

*Former Professor of Clinical Prosthesis.

581
582 Saizar J Prosthet.
December,
Dent.
1971

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Fig. 1. The temporomandibular articulation, sagittal section, representing a temporomarl-

dibular articulation in centric relation. (From Sicher.“)

the limits of the retrusive movement. Many authors have supported this theory.”
Like the muscle theory, it has a physiologic basis. Ligaments bind the elements of
the articulations, limit their possibilities of movement, and are also capable of
determining terminal border positions.
If we examine the position of the condyles within the glenoid fossae when the
jaw is fully retracted, as Ferrein2 did, we discover a retrocondylar space. It is possible
to insert a surgical instrument in front of the tympanic plate and touch the posterior
glenoid roof without displacing the condyle from its retruded position. Therefore, the
posterior wall of the fossa does not constitute a condylar stop. Moffet” eliminated
the tympanic plates without affecting the condylar positions.
When the condyle is seen in lateral radiographic views in centric relation, it ap-
pears to be “suspended” or “floating.” These views reinforce the theory that soft,
radiographically translucent tissues determine the final condylar position, and thr
temporomandibular ligaments fulfill these conditions.
Microscopic examination of sections of the temporomandibular articulation,
and the sagittal sections in particular (Fig. 1)) strengthens this interpretation be-
cause the condyle is seen to be surrounded by soft tissues which should not be con-
sidered to be terminal retrusive stops. Some empty spaces which appear between the
temporomandibular structures, and which may be observed in all sections, reinforce
this impression, even though they are caused by the histologic technique.
On the other hand, Ferrein,2 PosseIt,” and Arstad” found, in cadavers, that the
temporomandibular ligaments were “tense” when the jaw was in the terminal rc-
truded position.
Volume 26 Centric relation and condylar movement 583
Number 6

Fig. 2. The lateral aspect of right capsule. (I) External acoustic conduct, (2) longitudinal
root of zygomatic process, (3) postglenoid tubercle, (4) temporal muscle, (5) outer face of
articular capsule, (6) zygomatic tubercle, (7, 8) external pterygoid muscle fascicles, (9, 10)
masseter muscle fascicles, (21) mastoid process, (12) superficial temporal artery and vein,
(13) tympanic plate, (24) mandible, (15) styloid process.

The ligament theory adds many apparently related facts to the anatomic orga-
nization and offers a plausible physiologic explanation. But it does not clarify every-
thing.
For example, the anatomic arrangement of the temporomandibular ligaments
is not well suited to halt the retrusive condylar movement. Examination of the
temporomandibular ligament position (Fig. 2) shows that the ligamentous fibers
and the direction of the condylar sagittal path form an angle of almost 90 degrees.
This arrangement seems suited to resist the separation of the condyle from its
temporal sliding surface.
Another objection to the ligament theory arises from the fact that a ligamentous
retrusive terminal stop provides no satisfactory location for the hinge axis. Indeed,
if the temporomandibular ligaments constitute the retrusive terminal stops, the pos-
terior hinge opening must have its axis formed by the line connecting the ligamentous
fiber insertions at the condylar necks. Nevertheless, the hinge axis appears to be
centrocondylar in almost all of the studies that have been conducted, including the
author’s.
Saizar and Rothman* found the hinge axis in the centrocondylar position in both
sides of seven cadaver heads. These findings are in complete agreement with those
of McCollum.’ Boucher8 found that the centric relation mandibular position does
not change in the cadaver after section of the capsular ligaments.
In order to rule out the possibility that these results were due to postmortem
changes, Boucher* extended his observations to 27 patients in whom the temporo-
mandibular ligament had been sectioned. No change of the centric relation man-
dibular position was observed in any of the subjects.

*Unpublished data.
584 Saizar

Fig. 3. The disc over the condyle. (I) Upper anterior surface, (2) posterosuperior surface. (3,)
transverse ridge, (4) posterior fold, (5) external condylomeniscal ligament, (6) capsule, (7,)
mandible, (8) external pterygoid pterygoidal fascicle. (9) external pterygoid sphenoidal
fascicle, (10) anterior fold of floor of upper car.ity.

The ligament theory does not explain satisfactorily the lateral border move-
ments, because it cannot produce an acute gnathographic angle. It registers an
elliptical tracing. This statement may be verified by suspending a mandibular model
from nonelastic strings or tapes set to imitate the position of the ligaments. This will
produce a tracing of an elliptical shape, similar to the one described by Hall,” but
different from the natural tracing. The tracing remains elliptical when t\vo medial
ligaments are added, as shown by Arstad” and by Testut’s description of inner lateral
temporomandibular ligaments. After retrusion stops have been added, placed in
such a way that they simultaneously prevent lateral condylar movements. tracings
are obtained which coincide with the normal ones.

THE OSTEOFIBER THEORY

According to Posselt,” an osteofiber theory was proved by Meyer.l” ‘This theor).
involves a retrusive terminal stop formed by the soft tissues of the posterior part of
the roof of the glenoid fossa. Zenker I1 believed that this fibrous stop acts as a buffer.
and based his belief upon a histologic study of the retroarticular tissues. Along with
other modern authors, he found these tissues to be loose, fibrous, and functionall?
differentiated. He named this structure the “retroarticular cushion.”

THE MENISCUS THEORY

The author’s disc, or meniscus, theory, involves the fibrous stop. Study of the
upper surface of the disc (Fig. 3 j reveals a transverse ridge close to its posterior
edge. The posterior surface of this ridge faces up and backward, forming a nearly
straight angle with the large upper anterior surface. The upper posterior surface
may be seen, nevertheless, in all sections (Fig. 1 j, and accurately dissected speci-
mens. This surface has been shown in anatomic drawings since Hunter’s’? day. It
is 2 or 3 mm. wide by 2.5 to 3 cm. long.
If we observe the roof of the posterior part of the glenoid fossa when it is covered
by its fibrous tissues, we find the negative contours of both of the upper disc surfaces.
The accuracy with which they adjust may be checked by making impressions and
Volume 26 Centric relation and condylar mouement 585
Number 6

Fig. 4. The temporomandibular articulation in centric relation, sagittal section (semischematic).

(I) Condyle, (2) compact disc, (3, 3’) external pterygoid muscle, (4) temporal bone,
(5) upper articular cavity and (5’) its posterior fold, (6) fib rous posterior disc and (6’) fibrous
anterior disc, (7) retroarticular fibrous tissue, (8) lower cavity and (8’) its anterior fold,
(9) external acoustic conduct, (10) parotid gland, (:I) superficial temporal artery, (22)
auriculotemporal nerve, (I 3) cortex.

models of the roof of the glenoid fossa and upper side of the disc. When the disc is in
its postural position, or close to it, the upper synovial cavity continues down and back-
ward, within the retroarticular fibrous tissues. This important anatomic fact was
pointed out by Arstad.‘j
In the cadaver, sagittal sections of the temporomandibular joint show a cavity
between the roof of the glenoid fossa and the displaced retromeniscal tissues when
the disc slides forward. In a living subject, this cannot happen because there is no
fluid or air to fill this cavity. That is why the posterior fold should be able to slide
close to the roof of the glenoid fossa in the meniscal propulsions. This fold can be
seen in Fig. 1. It represents a sagittal cut through the temporomandibular articula-
tion with the condyle in its centric relation position. Once recognized, this fold pro-
vides a key to the meaning of the temporomandibular topography. We call it the rest
or postural posterior fold of the upper synovial cavity.
ReeP distinguished five areas in the disc structure, but we can find only three
(Fig. 4). The disc begins with a structure of relatively independent fibers in its
anterior pole (Fig. 4, 6). The fibers become compact in the midportion, and the
posterior part, starting from the transverse ridge, is once again vascular and formed
by separate fibers (Fig. 4, 6). Thus, the fibers in the central portion of the disc are
densely matted together, while at both poles, especially the posterior, the fibers can
be separated and unfolded. As can be seen in Figs. 1 and 4, the central, nonfolding
portion is located below the posterosuperior surface of the disc, just before the pos-
tural posterior fold.
There is another fold, which is anterior and constitutes a front postural exten-
sion of the lower cavity. This second fold was described by Rees,13 and it may be seen
586 Saizar .I. Prosthet. Ucnt.
December, 1971

Fig. 5. Right temporomandibular articulation frontal sectionz through meniscal transverse

ridge. (I) Temporal bone, (2) external surface of capsule: (3) inner insertion of capsule, (4)
inner lateral folds of superior cavity , (5) outer lateral fold of upper cavity, (6) inferior cavity.
(7) disc, (8) outer condylomeniscal ligament, (9) inner condylomeniscal ligament.

Fig. 6. Opening in outer face of capsule of temporomandibular articulation, showing upper

cavity and upper lateral surface of the disc (semischematicj

in all anteroposterior sections under the lower anterior disc surface (Fig. 4, 8’) I It
extends over the external pterygoid attachment fascicles which reach the condylar
neck.
The condylomeniscal ligaments, although they were mentioned in the earlier
literature,14 have long been disregarded. Their significance has recently been re-
emphasized by Krogh-Paulsen and Molhave,ls and it is now known that the discs
are not attached laterally on the capsule’s inner surface.
The upper cavity, seen in frontal section in Fig. 5, extends at both sides lower
than the inferior cavity because the disc, instead of being attached to the capsule,
bends following the condylar lines and becomes a fibrous tissue of lower density. In
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Fig. 7. Sagittal section of the temporomandibular articulation represented in Fig. 4, in pro-

pulsive gliding position. See Fig. 4 for the rest shape of the disc, cavities, and pre- and retro-
articular tissues. Line from center of condyle backward shows condylar path. An artificial
separation is shown between the fascicles of the external pterygoid to show that the lower
one is descended. (A) Retroarticular tissues are unfolded; (B) posterior fold of upper cavity
has disappeared; (C) posterior propulsive fold of lower cavity is initiated; (D) disc assumes
new shape; (E) anterior fold of lower cavity is reduced; (F) upper propulsive fold is initiated;
(G) lower fascicle of external pterygoid muscle has descended.

this way, the disc gives rise to the condylomeniscal ligaments, which are attached be-
low the medial and lateral condylar poles (ends) . This fact points up another
anatomic detail which we call the perimeniscal ditch. Fig. 6 shows an opening in the
outer surface of the capsule through which the outer face of the condylomeniscal
ligament is seen forming the inner wall of the above-mentioned ditch. A similar
situation exists on the inner surface of the condyle. Both lateral crevices and the
posterior one form a pit that surrounds the disc on three of its sides. This pit is 5
to 10 mm. deep, and it explains the relative freedom of movement of both disc and
condyle within the capsule.
All of the previously mentioned anatomic details contribute to temporomandibular
function and seem to explain centric relation. Indeed, when the condyle pulls the disc
forward during condylar propulsion (mandibular protrusion), the posterosuperior
surface unfolds along the roof of the glenoid fossa, because the posterior fibrous disc
structure allows that unfolding through the mobilization and separation of the
fibrous fascicles, while its ducts swell, as pointed out by Zenker.l’ Fig. 7 shows
how the posterosuperior facet adapts to this movement as if it were a flexible
sliding curtain, while the posterior fold slides upon itself almost to the place where
it disappears. Simultaneously, the premeniscal capsule starts folding, thus originating
a front upper propulsion groove.
Different sliding motions occur in the anterior fold of the lower cavity. When
the condylar propulsion begins, this cavity opens and yields to the condyle, which
occupies it, thus enabling it to overtake the disc. As a consequence, the precondylar
fold disappears. As the condyle moves forward, a retrocondylar fold is formed, as
Rees13 pointed out.
588 Saizar

Fig. 8. The temporomandibular articulation, sagittal section, represented in Fig. 3; with mouth
fully open. Check Figs. 4 and 7, for the shape of the disc, cavities, and pre- and retroarticular
soft tissues. Notice also the position of candyle and of external pterygoid fascicles, which arc
artificially separated in order to show the lower t>nc dcsl-rnded. The length of the condylar
path, as shown by the line, has greatly incrrased. (A) Retroarticular tissues are unfolded;
(B) posterior fold of upper cavity has disappeared; (Cj lower propulsive fold is seen; (D)
disc assumes new shape; (E) anterior lower fold is occupied by the condyle; (F) upper pro-
pulsive fold is seen; (G) pterygoid fascicle of external pterygoid muscle has descended.

At the time of maximum meniscal propulsion which occurs when the mouth is:
fully open (Fig. 8)) the upper retromeniscal groove disappears, and is replaced b)
a premeniscal one of equivalent dimensions. The lo’wer cavity has originated a
retrocondylar groove equivalent to the one that disappeared in front. During the
whole movement, the disc alters its shape, continuously adapting to the changing
cavity that contains it.
The condylomeniscal propulsion characteristics result from the disc resilience and
the presence of folds of the upper and lower cavities. Through these folds both
cavities slide over themselves, forming two new folds: a premeniscal fold for the
upper cavity and a retrocondylar one for the lower cavity. We believe these folds
should be called propulsive folds (Fig. 8, C, F) . The sliding of the discs is aided b)
the lateral grooves and by the periarticular soft tissue movement, as well as by the
synovial fluid.
The noticeable external phenomena of the condylar movement, such as the
sinking and projection of the skin and of the external auditory tract wall, are well
known. Those soft tissue movements are needed to fill the gap, since without them
the condyle would be prevented from going forward or backward, and they appear
also at the posterior fibrous disc level. Those fibers, which are arranged in vertical
columns when the articulation is at rest, and among which flow several ducts, ac-
cording to Zenker,ll fold or unfold following the condylomeniscal movements, and
they tend to become horizontal when their lower attachment slides forward (Fig.
7). When they stretch to a state of tension, they- may constitute that ligament or
posterior meniscal stop that has been described by French anatomists since the time
of SappeylG (Figs. 7 and 8, A).
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Fig. 9. The temporomandibular articulation, sagittal section, represented in Fig. 4, in hinge-

axis opening position (opening from centric relation). Black dots and arrows indicate the
approximate change in the position of several anatomic areas as compared with centric rela-
tion occlusal position. (A) Supposed axial zone is seen; (B) anterior condylar end of lower
cavity has descended; (C) anterior fold of lower cavity has shortened (posterior or propulsive
fold of lower cavity may be initiated) ; (0) 1ower fascicle of external pterygoid muscle has
descended (separation between both fascicles ,is artificial) ; (E) cervical insertion of lower fas-
cicle of external pterygoid muscle is retruded; (F) disc position is not changed. (All changes
may differ somewhat due to the variations in the shape of the condyle and the other temporo-
mandibular structures.)

Zenkerll and Findlayl? were able to prove experimentally the existence of the
pressure increase that eliminates the fluids during condylar retrusion and the decrease
that recalls them during propulsion. A similar fact had previously been found in
rats by Cabrini and Erausquin. I8 Parsons and Boucherlg demonstrated that this is
not an erectile mechanism, as Rees13 suggested. The author feels with Findlayl? that
its action is purely passive, aided in the return motion by the elastic fibers of the
posterior meniscocapsular area. Condylar movements change the position of the
soft paracondylar tissues in the same way that closing the fist drags the skin and the
soft tissues, thus modifying the folds of the palm.
It is easy to infer that the above-mentioned movements occur inversely when
the condyle returns. During sliding retrusion, the condyles are stopped in centric
relation when the discs cannot go farther back, halted by the fitting of the postero-
superior facets against their deep glenoid negatives. It seems evident that the discs,
with the retromeniscal fibrous tissues, function as buffers, thus stopping the re-
trusive condylar movements by fitting exactly between the bony surfaces.
In turn, the bony surfaces cause that close fit, establishing the unchanging shape
of the rigid box which, in centric relation, contains the soft posterosuperior retro-
articular tissues, shrunk to their minimum volume. This instant arriva1 at a state
of minimum volume, which is facilitated by the simple expulsion of the fluids, ac-
counts for the abruptness with which the mandible comes to a halt during the
retrusive backward sliding motion.
The retrusive terminal stop mechanism exists unchanged in edentulous sub-
590 Saizar J. Prosthet. Dent.
December, 1971

jects. A person who has teeth does not usually use this mechanism because inter-
cuspation at the dental arch level, prevents the condyles from sliding to their more
retrusive positions.20
The centric relation mandibular position, passive as far as the stop mechanism
that causes it, is a myologically active position whenever it is voluntary. In order
to reach it and maintain it, a subject must retain the predominance of the retro-
pulsive and elevating muscle structure.21
When the muscles return to their rest positions, the condyles abandon their
terminal retrusive positions, the elastic fibers under stress relax, the displaced fibrous
tissues are released, the interstitial lymph and the synovial fluid are redistributed,
and the compressed vessels swell again. In the rest mandibular position, the
temporomandibular joints are also at rest, and the condyles are not in the positioir
of centric relation.
The clinical unity of centric relation, and the gothic arch vertex that repre-
sents it, can be explained in terms of the osteofibrous niches that prevent trans-
verse sliding. This explains the constancy of the centric relation position, as well
as that of the rotation centers which determine border movements, despite the
severance of the ligaments and capsule. On the other hand, severance of an ex-
ternal men&al pole allows a new and different transverse sliding, as well as the
appearance of amazing gnathographic tracings. Otherwise, the centric relation
unity is preserved in varied vertical dimensions, as has been demonstrated by El-
Aramany, George, and Scott.22
It is evident that this unity, which can be easily demonstrated gnathographically
by the return of the tracing needle to the vertex, and by the clearly angular shape
of the tracing, cannot be micrometric. Different degrees of the muscular contrac-
tion that causes the active centric relation (the one reached by the patient 1
determine functional variations of the same kind as those that are determined in
a clenched fist that tightens, as proved by Grass0 and Sharry.23
It is clear that the posterior hinge opening is achieved through inframeniscal
condylar rotations, while the discs retain their retrusive terminal positions (Fig.
9) .I01 24 The elevator and depressor muscles can move the jaw upward or down-
ward while the retropulsive muscles hold the discs and the condyles in their postero-
superior positions.

SUMMARY
Temporomandibular kinetics have been clarified by such anatomic facts as the
postural and propulsive folds of both cavities, the unfolding anterior and posterior
fibrous parts of the disc, the condylomeniscal ligaments and perimeniscal pit, and
the posterosuperior meniscal facet with its deep glenoid fossa negative.
Centric relation, with its clinical characteristics of abruptness, bilaterality, unity,
and repeatability, is determined by the fitting of the discs that act as buffers and
mufflers simultaneously between the condyles and the front parts of Glaser’s fis-
sure. In a living subject, the displacement of fluid gives a hydraulic character to
the mechanism. The hinge movement, in turn, seems to be an inframeniscal bi-
condylar rotation, with the discs halted in centric relation.
;;l;re,e, $5 Centric relation and condylar movement 591

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