The Relationship Between Centric Occlusion and The

Maximal Intercuspal Position and Their Use as Treatment

Positions for Complete Mouth Rehabilitation: Best Evidence
Consensus Statement
Mathew T. Kattadiyil, BDS, MDS, MS ,1 Abdulaziz A. Alzaid, BDS, MS,2,3 & Stephen D. Campbell, DDS,
MMSc 4
1
Advanced Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, CA
2
Prosthetic Dental Science Department, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International
Medical Research Center, Riyadh, Saudi Arabia
3
Prosthodontics and Digital Technology, Loma Linda University School of Dentistry, Loma Linda, CA
4
Restorative Dentistry, University of Illinois at Chicago, Chicago, IL

Keywords Abstract
Intercuspal position; centric relation;
prosthodontic rehabilitation; occlusion;
Purpose: The purpose of this Best Evidence Consensus Statement was to evaluate
maximal intercuspal position. the existing literature relative to two focus questions: How often does centric occlu-
sion coincide with maximal intercuspal position in dentate and partially dentate popu-
Correspondence lations?; and should centric occlusion or maximal intercuspal positions be equivalent
Dr. Mathew T. Kattadiyil, 11092 Anderson for dentate and partially dentate patients undergoing complete mouth rehabilitation?
Street, Loma Linda, CA 92350. E-mail: Materials and Methods: Keywords used in the initial search were: intercuspal posi-
[email protected] tion, centric occlusion, centric relation, maximal intercuspal position, prosthodontic
rehabilitation, and occlusion. The search was then limited to Systematic Reviews,
Disclosure: No conflict of interest Randomized Controlled Studies, Meta-analyses and Clinical Trials.
Results: The initial search strategy related to the selected search terms resulted in
Accepted December 17, 2020
more than 15,000 articles. When the subsequent search was limited to Systematic
Reviews, Randomized Controlled Studies, and Meta-Analysis and Clinical Trials,
doi: 10.1111/jopr.13316
313 articles were selected for further analysis.
Conclusions: Review of the literature reveals that most dentate and partially dentate
patients do not have coincident centric occlusion and maximal intercuspal position.
There is support for coincidence between centric occlusion and maximal intercus-
pal position as the preferred occlusal relationship in complete mouth rehabilitations.
The literature does not report conclusive evidence of adverse prosthodontic outcomes
with complete rehabilitations in centric occlusion or maximal intercuspal position in
a healthy population. However, there is support for an association between centric
occlusion-maximal intercuspal position discrepancies and occlusal instability as well
as temporomandibular joint disorders. Hence, it is concluded that partially and com-
pletely dentate patients requiring complete mouth rehabilitation should be restored in
centric occlusion.

Nomenclature revisions have occurred over the years in keep- intercuspal position, intercuspation, maximum intercuspation,
ing with emerging scientific evidence and accepted expert and centric occlusion (CO).
opinion.1,2 At times, these changes have led to some misper- Occasionally, descriptions of MIP have been confused with
ceptions, as well as debates as to how observations are named, the term CO, creating additional challenges in searching
or devices described and what they really mean. Centric and critically appraising the literature. For example, searches
relation (CR) has been described with different terminology in for CO may result in identifying disparate outdated litera-
the literature such as the retruded condylar position, retruded ture, while more recent publications on CO are based on
contact position, retruded axis position, hinge axis, transverse the occlusion with the condyles in CR. This finding re-
horizontal axis, and seated condylar position.1,3–8 Similarly, quires an awareness by the reader or researcher to distin-
maximal intercuspal position (MIP) has been referred to as the guish between past changes compared to current accepted

26 Journal of Prosthodontics 30 (2021) 26–33 © 2021 by the American College of Prosthodontists

Kattadiyil et al Impact of Centric Occlusion and Maximal Intercuspal Position

terminology, hopefully with less debate, greater dialogue and a served in 88% of the subjects. The average CO-MIP discrep-
better understanding. ancy at the mandibular incisor region antero-posteriorly was
The Glossary of Prosthodontics Terms1 defines centric re- 1.25 ± 1.00 mm and caudally 0.9 ± 0.75 mm. Hodge and
lation as the maxillomandibular relationship, independent of Mahan11 evaluated 101 patients using a position gnathome-
tooth contact, in which the condyles articulate in the anterior- ter to measure mandibular movement from CO to MIP and
superior position against the posterior slopes of the articu- reported a difference in 56% of the patients with an average
lar eminences; in this position, the mandible is restricted to horizontal and vertical discrepancy of 0.44 ± 0.54 mm and
a purely rotary movement; from this unstrained, physiologic, 0.47 ± 0.64 mm, respectively.
maxillomandibular relationship, the patient can make vertical, Rieder12 used a simple technique with scribed lines on the
lateral or protrusive movements; it is a clinically useful, re- mandibular and maxillary incisors of 323 subjects. Horizon-
peatable reference position. Centric occlusion is defined as the tal and vertical differences between CO and MIP were found
occlusion of opposing teeth when the mandible is in centric in 86% of the population studied. Shildkraut et al13 com-
relation; this may or may not coincide with the maximal in- pared the reliability of cephalometric measurements at CR us-
tercuspal position.1 Maximal intercuspal position is defined as ing a mandibular position indicator on patients with a CO-
the complete intercuspation of the opposing teeth independent MIP discrepancy. The subjects included 68 patients (64 ado-
of condylar position, sometimes referred to as the best fit of the lescents and 4 adults) selected from 131 consecutively treated
teeth regardless of the condylar position.1 orthodontic patients. The study group had a 2.0 mm or greater
The purpose of this Best Evidence Consensus Statement is CO-MIP discrepancy as measured with a mandibular position
to review the literature to answer two focus questions related indicator on articulator mounted casts. Cephalometric imaging
to CR, CO, and MIP. revealed that the condyles were seated inferior and posterior in
MIP when compared to CR. While the vertical component was
Focus question 1: How often does CO greater than the horizontal aspect in 96% of the subjects, 10%
coincide with MIP in dentate and of the subjects had only a horizontal component. Henriques
partially dentate populations? et al14 evaluated the condylar positions through radiographic
analysis on 20 young adult patients. They noted small discrep-
Search terms used were: centric occlusion, centric relation, ancies in average measurement values in 90% of the subjects,
condylar position, maximal intercuspal position and intercus- but reported these discrepancies were not statistically signifi-
pal position. cant.
The search strategy was related to the two focus questions Shafagh et al15 used a Vericheck instrument to determine the
and limited to Systematic Reviews (SR), Randomized Con- reproducibility of condylar positions in CR. They found a sig-
trolled Studies (RCT), Meta-analyses, and Clinical Trials. As nificant difference in diurnal and nocturnal CR recordings for
an example of the search process, initial search results for most of the 13 dental students who had recordings done at 3
term occlusion without any filters applied yielded more than different time intervals (9AM, 3PM, and 9PM). They attributed
220,000 results. This included medical topics which deviated their findings to changes in the TMJ fluid content throughout
from the topic of interest. Searches for CR, CO, MIP, intercus- the day. These findings concur with the findings of another
pal position, condylar position and prosthodontic rehabilitation study by Latta,16 although this study was on an edentulous pop-
yielded 2,096; 3,369; 287; 774; 1694 and 13,794 results re- ulation.
spectively. Titles were reviewed and selected if they related to Cordray17 in a 3-dimensional analysis of condylar posi-
the focus questions for further evaluation and selection. When tion on 536 asymptomatic orthodontic patients found that the
limited to SRs, RCT’s and Meta-Analysis, and Clinical Trials condyle was vertically displaced from CR in 97% of indi-
among all search terms, 138 articles were selected for further viduals and most frequently positioned posteriorly when teeth
analysis. The varying terminology in prosthodontics over the shifted to MIP. The condylar position for CR was located su-
years was factored into the report preparation. The terminology perior to the condylar position when the patient was in MIP.
used in this paper reflects the current edition of the Glossary of Cordray concluded that condylar location that was directed
Prosthodontic Terms. by the occlusion (MIP) was significantly different from the
Centric relation (CR) is a condylar position that has been condylar location in CR. These findings are in agreement
vigorously discussed over the years. The application, repro- with the current definition of CR. Lelis et al18 examined the
ducibility, positional accuracy, recording ability and reliability condylar positions in 20 subjects with symptoms of temporo-
of CR as a treatment position in complete mouth rehabilitation mandibular disorders (TMD) compared to 20 asymptomatic
has been investigated.9 There are many research and opinion young adult subjects. They reported that CO-MIP discrep-
based publications on the selection of CR and CO for com- ancies were found in 83.4% of the symptomatic groups and
prehensive rehabilitation. In contradistinction, there is minimal 85.0% of the asymptomatic groups, which was not statistically
evidence-based support for the use of the MIP as a starting significant.
treatment position in complete prosthodontic rehabilitations. Ismail et al19 in a radiographic study of 40 patients as-
The occurrence of a CO-MIP discrepancy has ranged from sessed the spatial positioning of the condyles in the mandibu-
56% to 100% in multiple studies and has been considered to lar fossa when the mandible was in CO and MIP. They found
be the norm for most of the population.10–12 Posselt10 in 1952 that the condyles were positioned superiorly and posteriorly in
studied superimposed cephalometric radiographs on 50 dental CO compared to MIP. In a cone beam computed tomography
students and reported that the CO-MIP discrepancy was ob- (CBCT) study, Ferreira et al20 compared condylar positions in

Journal of Prosthodontics 30 (2021) 26–33 © 2021 by the American College of Prosthodontists 27

Impact of Centric Occlusion and Maximal Intercuspal Position Kattadiyil et al

CR and in MIP and concluded there was no statistically signifi- Focus question 2: Should CO-MIP
cant imaging difference between those two positions. However, positions be equivalent for dentate and
this study included a low subject number of only 10 asymp- partially dentate patients undergoing
tomatic young adults. complete mouth rehabilitation?
Utt et al21 used a mandibular position indicator to compare
condylar position in CO and MIP in 107 patients. Only 1 pa- Search terms used were: maximal intercuspal position, inter-
tient had a coincident CO-MIP position in all 3 spatial planes. cuspation, intercuspal position, centric occlusion, centric rela-
They reported that the average difference was 0.61 mm antero- tion and prosthodontic rehabilitation.
posteriorly, 0.84 mm supero-inferiorly and 0.27 mm laterally Initial search results for these search terms without any fil-
for the majority of subjects. 19% of the subjects had a CO- ters applied yielded more than 18,509 results. This included
MIP sagittal discrepancy greater than 2.0 mm. In a study con- medical topics which deviated from the topic of interest.
ducted on 28 healthy adults (22-35 years old) with an Angle’s Searches for MIP, intercuspation, intercuspal position CO, CR,
Class I jaw relationship, Alexander et al22 used magnetic res- and prosthodontic rehabilitation yielded 155; 1158; 774; 3374;
onance imaging of the condyles and reported a significant and 2096; and 13,794 results, respectively. SRs, RCT’s and Meta-
distinct difference in jaw position between CO and MIP condy- Analysis, and Clinical Trials among all search terms resulted
lar positions. They reported the condylar position in MIP to be in 2219 articles. Titles were reviewed and selected if they re-
inferior and anterior to CR as a result of deflective occlusal lated to the focus questions for further review and selection.
contacts. One hundred and seventy-five articles were selected for further
analysis.
Clear scientific evidence is lacking when comparing com-
plete mouth rehabilitation outcomes in CO or MIP. This ob-
Discussion servation may be because CR and CO is generally consid-
Roth and Rolf 23 explained that deflective occlusal contacts ered to be reliable and reproducible reference locations dur-
during jaw closure in CO causes a mandibular slide into MIP ing complete arch rehabilitations.9 It is believed that the su-
in an attempt to obtain a stable uniform occlusal position. This perior anterior position of the condyles in the glenoid fossa
altered jaw closure is what creates intercuspal and condylar in CR reduces the potentially harmful deflective contacts in
position discrepancies. According to the authors, the signifi- excursive movements.13,17,19,23 During the literature searches
cance of this slide and the resulting CO-MIP discrepancy is multiple studies investigated the association between CO-MIP
that premature tooth contacts could lead to increased leveraged discrepancies and TMD.24–33
occlusal forces from the irregular jaw closure during mastica- Hellman et al34 conducted a study on condylar positions in
tion or from parafunctional activities that would have a higher CO before and after a simulated reconstruction. Occlusal de-
potential for injury to the temporomandibular joints. vices were fabricated on 41 dental students in CR. Records
The literature search revealed multiple methods to record the were obtained by asking the subjects to position the tip of the
differences of condylar positions in CO and in MIP. Condylar tongue at the posterior aspect of the palate combined with guid-
position indicators have been used with a variety of articula- ance of the mandible by the operator. The authors placed and
tors and visually demonstrate and allow measurement of the adjusted the occlusal devices in CR until the occlusal contact
dissimilar condylar positions between CO and MIP in three was uniformly achieved within 10 micrometers. Using a mod-
planes. Currently, there is no specific term that has been used ified ultrasonic telemetry system, they reported that CR was
in the dental literature to describe the altered condylar position reproducible before and after simulated reconstruction within
when the mandible is in the MIP. Therefore, it is proposed that a spatial accuracy of 0.3 mm.
the Glossary of Prosthodontic terms consider adding terminol- Manfredini et al35 stated that there is no scientific correlation
ogy that describes the condylar position in MIP using a term between TMD and occlusion at different condylar positions.
such as Condylar Maximal Intercuspation Position (CMIP). This statement implies that both CO and MIP are acceptable
rehabilitation positions. In a systematic review that included
data from 25 selected articles, the authors reported an asso-
ciation between TMD and mediotrusive occlusal interferences
Focus Question 1: Evidence-based conclusions and a weaker association with a CO-MIP discrepancy. Their
1. A coincident CO-MIP does not occur in the majority of findings were not in agreement with the views stated in the
the population. conclusion of their publication.
2. There is a circadian influence when recording CR. In a lateral cephalometric study, Ekberg et al32 compared
3. Relative to the vertical position, the CO condylar posi- the effects of occlusal devices fabricated in CO and MIP for
tion is more superiorly located compared to the condylar patients with TMD of arthrogenous origins. They found that
position in MIP. occlusal devices fabricated in CR resulted in a change in the
4. Relative to the horizontal and transverse positions, the condylar position. This change was believed to lead to a better
MIP condylar position is variable compared to the treatment outcome that reduced TMD symptoms as compared
condylar position when the mandible is in CO. to occlusal devices fabricated at MIP. However, for TMD pa-
5. It is recommended that the Glossary of Prosthodontic tients of myogenous origin, both CO and MIP occlusal devices
Terms add terminology related to the Condylar Maximal had similar effects in mandibular repositioning, muscular ac-
Intercuspation Position. tivity and pain reduction.33

28 Journal of Prosthodontics 30 (2021) 26–33 © 2021 by the American College of Prosthodontists

Kattadiyil et al Impact of Centric Occlusion and Maximal Intercuspal Position

A recent MRI study by Kandasamy et al36 recorded the CO-MIP discrepancies. However, due to a lack of consistent
condylar positions in CR achieved by using 2 different tech- results among the studies reviewed it was not possible to deter-
niques (chin point guidance and Roth power centric) and in mine any definite conclusions.
MIP. They reported no significant differences and advocated Hamata et al33 in a randomized controlled trial on 20 TMD
using MIP instead of CO when treating orthodontic patients. patients compared occlusal devices fabricated in CO and MIP
MIP was assumed to be a non-pathological physiological po- to muscle pain reduction. The 20 patients with TMD of myo-
sition that patients adapted to and that any condylar position genous origin and bruxism were divided into two groups that
changes are unnecessary and might be harmful. were treated with occlusal devices designed in either in CO
Crawford24 compared patient histories, clinical examinations or MIP. Clinical, electrognathographic and electromyographic
and condylar position indicator (CPI) measurements data be- examinations were performed before and three months after
tween 30 complete mouth rehabilitation patients who had been placement of the occlusal devices. They reported that both or-
restored with a coincident CO and MIP and a control group of thoses were effective for pain control and effectiveness. The
30 untreated patients. They reported that patients who had been results suggested that MIP may be used for fabrication of oc-
restored using CR as a reference position revealed lower CPI clusal devices in patients with occlusal stability without large
values (<1.0 mm) along with an 84% reduction in symptoms. CO-MIP discrepancies.
They concluded a high correlation existed between the signs A detailed report regarding TMD and CO-MIP discrepancy
and symptoms of TMD and higher CPI values. will be provided in another BECS.
Lim et al26 reported that adult patients with backward posi- Most of the studies that did not report significant CO-MIP
tioning and rotation of the mandible should be carefully eval- condylar discrepancies were observed on subjects who were
uated as a possible consequence of a CO-MIP discrepancy. young adults or the study design had a small sample size.14,18,20
They classified and studied adult female patients seeking or- However, Alexander et al22 who also studied a younger adult
thodontic treatment into 2 groups, one group of 20 subjects population reported a CO-MIP discrepancy in half of the popu-
with large CO-MIP discrepancies greater than 2.0 mm and a lation studied. Cordray25 reported on his analysis of 1192 sub-
second group of 27 subjects with less than 1.0 mm discrep- jects, also consisting a younger population of which 596 were
ancies. Lateral cephalograms were analyzed to identify differ- symptomatic with TMD and 596 were asymptomatic. The au-
ences in 16 cephalometric variables between CO and MIP in thor studied articulated dental casts of subjects mounted in CR
subjects with larger discrepancies. The test group with larger to determine condylar displacement in CO and MIP for asymp-
discrepancies had posterior positioning and clockwise rotation tomatic and symptomatic subjects using a Panadent Condyle
of the mandible along with TMJ disc displacement. Position Indicator. All subjects displayed a displacement be-
Padala et al27 in a study of 40 patients reported signifi- tween CR and condylar position in MIP in at least 1 plane. The
cantly greater vertical and horizontal condylar discrepancies magnitude of condylar displacement was higher in the hori-
between CO-MIP for symptomatic subjects compared to non- zontal, vertical and transverse direction for the symptomatic
symptomatic subjects. Weffort and de Fantini28 in a study on subjects.
70 individuals, reported the significance of discrepancies in the Techniques used to evaluate CO-MIP discrepancies included
transverse plane with TMD symptoms. They stated that trans- cephalometric radiographs, CBCT, magnetic resonance imag-
verse plane discrepancies greater than 0.5 mm were more likely ing, condylar position indicators, and Gnathometer. Table 1
to have TMD symptoms. In another study, He et al29 conducted lists the relevant studies and information used to answer focus
a study on 177 patients who were divided into two groups: questions 1 and 2.
symptomatic and non-symptomatic patients. They found that Based on the above studies, there appears to be some support
72.9% of the symptomatic TMD patients had CO-MIP discrep- for an association in the literature that subjects with larger CO-
ancies compared to only 11.4% in the non-symptomatic group. MIP differences had a greater association with TMJ symptoms.
Rosner and Goldberg30 studied condylar positions in CO
and MIP in a population of 75 patients. They used a condy- Discussion
lar recording instrument attached to the articulator to study rel-
ative condylar positions at CO and MIP using scattergrams. In 2005, Baker et al38 reported on a dental educators’ survey
This data was used in a subsequent report that correlated a on maxillomandibular relationship philosophies in the United
patient questionnaire with the scattergrams from their first States regarding prosthodontic restorations. They concluded
study.31 They reported a significant difference in the sagit- there was a continuing controversy regarding the preferred
tal peripheral outline between the group of 38 patients with- mandibular position for treatment of dentulous and partially
out primary symptoms and the group of 37 patients with one edentulous patients among dental educators at both the pre-
or more primary symptoms of mandibular dysfunction. There doctoral and postdoctoral levels in the United States. In 2012,
were higher peripheral scattergrams for the subject groups that the American College of Prosthodontics Task Force on As-
were symptomatic.31 sessment of Occlusion Curriculum performed a survey on oc-
A systematic review by Silva et al37 reported that there clusion education. Forty-eight dental institutions in the United
was no association between CO-MIP discrepancies and TMD. States responded to the survey with a total of 83 respondents.
They narrowed their initial search from 467 articles to 20 ar- Relative to topics on CR, CO, and MIP the educators stated
ticles from which data was collected for analysis. The authors these topics are normally included 88 to 98% of the time.39
found the quality of evidence to be low but did note a corre- Prior to the GPT-9th edition, Goldstein et al9 conducted a
lation between muscle and joint disorders, when compared to study among the Fellows of the Academy of Prosthodontics

Journal of Prosthodontics 30 (2021) 26–33 © 2021 by the American College of Prosthodontists 29

30
Table 1 List of relevant studies and information used to answer focus questions 1 and 2

CO/CR- MIP discrepancy

First author Study type Sample size Technique (%) TMD association reported
10
Posselt Clinical 50 Cephalometric 88% NA
Hodge11 Clinical 10 Gnathometer 56% NA
Rieder12 Clinical 323 Direct measurements 86% NA
Shildkraut13 Clinical 68 Cephalometric 96% NA
Henriques14 Clinical 20 CBCT 90% NA
Shafagh15 Clinical 13 Vericheck instrument 100% NA
Cordray17 Clinical 536 Articulator measurements 97% NA
Lelis18 Clinical 40 CBCT 83.4%/85% No
Ismail19 Clinical 40 Radiographic
Ferreira20 Clinical 10 CBCT NA
Impact of Centric Occlusion and Maximal Intercuspal Position

Utt21 Clinical 107 Mandibular position 99.1% NA

indicator
Alexander22 Clinical 28 Magnetic Resonance 50% NA
Imaging
Crawford24 Clinical 60 Condylar position indicator Yes
Cordray25 Clinical 1192 Condylar position indicator 100% Yes
and cast measurements
Lim26 Clinical 47 Cephalometric 100% Yes
Padala27 Clinical 40 MCD (measured condylar Yes
deviation) device
He29 Clinical 177 Condyle position indicator 84.3% Yes
(1 mm vertical or
horizontal, 0.5 mm
transverse)
Rosner30 Clinical 75 Condylar recording Yes
instrument
Manfredini35 Systematic Review No/Yes
Silva37 Systematic Review No
Kattadiyil et al

Journal of Prosthodontics 30 (2021) 26–33 © 2021 by the American College of Prosthodontists

Kattadiyil et al Impact of Centric Occlusion and Maximal Intercuspal Position

to determine whether there was agreement on the definition of Focus question 2: Evidence-based conclusions
CR. The response rate was 86% (n = 83). The authors also
1. As a reference position, CR provides a physiologic, reli-
noted areas of both agreement and disagreement regarding the
able and reproducible treatment position for performing
definition of CR. This variance was attributed to different train-
complete mouth rehabilitations.
ing period and education eras of the respondents. When asked
2. There appears to be an association between CO-MIP dis-
about a preference between MIP and CO/CR when restoring
crepancies and TMJ symptomatology.
both maxillary and mandibular arches, 92% of respondents
3. Prosthodontic rehabilitations of TMD patients should
preferred CR compared to 5% who chose MIP. When asked
occur only after a stable condylar (CR) and CO position
about a preference when restoring one complete arch, 80% of
have been established.
the respondents preferred CR compared to 16% who preferred
MIP.
Occlusal interferences in the anterior-posterior, vertical and Consensus statement
lateral planes are well documented in the CO-MIP discrepancy There is supporting evidence that even though CO-MIP are
literature presented here. As such, the impact of interferences not coincident in the majority of the population, complete
is an important consideration. Posterior tooth loss has been re- prosthodontic rehabilitations in CO-MIP is the preferred treat-
ported to influence occlusal stability and initial contact in CO ment methodology. The literature also suggests an associa-
and associated with higher number of occlusal interferences. tion between CO-MIP discrepancies and TMJ symptomatol-
Craddock40 reported a comparison study on 100 test and con- ogy. There is documentation that the condyles in CR are in a
trol patients to determine if posterior tooth loss was associated superior and anterior position in the glenoid fossae. This is con-
with occlusal interferences in CO. Test subjects had multiple sidered a predictable, physiologic, reliable and reproducible lo-
and control subjects had fewer types of interferences. The au- cation from which pathologic occlusal contacts are minimized
thor concluded that unopposed posterior teeth were more likely in excursive movements. Complete mouth reconstructions in
to be involved with occlusal interferences when compared to MIP on patients with CO-MIP discrepancies have not been
their matched controls. Occlusal interferences were associated widely reported. This may be because they lead to adverse
with the degree of supraeruption of the unopposed tooth and outcomes, and/or this is not a complete mouth prosthodon-
resulting tooth migration due to the posterior tooth loss. tic rehabilitation philosophy taught in most prosthodontic
Consequences and sequela as a result of CO-MIP discrepan- programs.
cies that might impact complete prosthodontic rehabilitations The authors believe that the adaptive capacity of each in-
have not been extensively studied to draw meaningful conclu- dividual play a significant role in overcoming some of the
sions. Topics like prognosis, outcomes, complications, main- potential harm that can occur from a ‘less than ideal’ oc-
tenance, survival, fractures as well as biological sequela like clusal scheme. However, the repeatability, the predictable
inflammation, gingival health, probing depths, bone loss have and safe envelope of function from CR makes it a desir-
not been examined relative to CO-MIP discrepancies. And fi- able diagnostic and treatment position in complete mouth
nally, patient outcomes such as satisfaction, comfort, quality of prosthodontic reconstructions. The evidence identifying de-
life, esthetics and function are of great importance but have yet creased TMJ symptomatology in patients with little or
to be examined relative to CO-MIP discrepancies. no CO-MIP differences further supports the concept of a
Other observations during the initial search included several coincident CO-MIP as a preferred position for complete
case reports predominantly from one group of authors who mouth rehabilitation of the dentate and partially dentate
described techniques for complete mouth rehabilitation with patient.
complete or partial coverage restorations in MIP.41–45 It was
noted that patients did not have TMD or reported occlusal in- Consensus conclusions
stability prior to treatment. The authors did not observe any
complications following treatment completion. Long term out- Review of the literature reveals that most dentate and partially
comes data were not presented, and these articles were not in- dentate patients have CO and MIP positions that are not coin-
cluded as they did not meet the search inclusion criteria. How- cident. There is support for coincidence between CO and MIP
ever, they are mentioned to provide a balanced perspective, yet as the preferred occlusal relationship in complete rehabilita-
with the lack of overwhelming evidence, prudence is indicated. tions. The literature does not report conclusive evidence of ad-
In what can only be considered a weaker form of scientific verse prosthodontic outcomes with complete rehabilitations in
evidence gleaned mostly from expert opinion, the authors agree CO or MIP in a healthy population based on the search criteria
that complete mouth rehabilitations should be performed in used. However, there is support for an association between CO-
CR/CO. Also, it is the opinion of the authors that deflective MIP discrepancies and occlusal instability as well as TMD. As
occlusal contacts should be identified and eliminated to fully a result, it is concluded that partially and completely dentate
manage the functional occlusion in complete mouth rehabilita- patients requiring complete mouth rehabilitation should be re-
tions. In addition, the authors take a teleological viewpoint in stored in CO. Well-defined prospective clinical trials that focus
regard to CR. It is a position that is reliable during rehabilita- on clinical outcomes and long-term complications are needed.
tions that include single complete arches or both arches. There It is further recommended that the Glossary of Prosthodontic
is evidence based on expert opinions and studies on TMD that Terms examine the concept of the Condylar Maximal Inter-
CR achieves a condylar position that is physiologic, reliable cuspation Position and add terminology related to the condylar
and reproducible during complete mouth rehabilitations. position in MIP.

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Impact of Centric Occlusion and Maximal Intercuspal Position Kattadiyil et al

23. Roth RH, Rolfs DA: Functional occlusion for the orthodontist.
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