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METHODS OF RECORDING
RETRUDED POSITION IN
DENTATE PATIENTS
By: Yossr Mokhtar
OUTLINE
A) Definition of RCP
B) Importance of RCP
In dentate patients
In edentulous patients
C) Uses of RCP in dentate patients
D) Factors affecting RCP recording
E) RCP registration materials
F) Mandibular guidance and RCP
G) Different methods of recording RCP
A. Patient guided recording
B. Operator guided recording
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A)) Definition of Retruded Contact
Position (abb. RCP)
• It is the contact of a tooth or teeth along the
retruded path of closure. (GTP9)
• It is the initial contact of a tooth or teeth during
closure around a transverse horizontal axis. (GTP9)
• It is the guided occlusal relationship occuring at a
most retruded position of the condyles in the joint
cavities .A position that may be more retruded than
the centric relation.
In DENTATE Patients :
Posselt, in 1952, found that in 10% of dentate
individuals , the RCP
coincided with the
intercuspal position ICP.
The remainder 90% had
RCP inferoposterior
to the ICP by 0.5 to 2 mm.
This movement from RCP
to ICP is known as a Posselt’s sagittal envelope of mandibular border
movements.
“SLIDE”
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B)) The importance of RCP :
Being a relatively reproducible position, makes
the RCP useful in :
C)) Uses of RCP :
1) Restorative management of dentate and
edentulous patients
2) As a reference point for the registeration of
transfer records ,so that casts can be mounted
on articulators.
3) Re-organising a patient’s occlusion at a new
vertical dimension.
4) Occlusal analysis in cases of toothwear, tooth mobility,
drifting, pain or repeatedly failing restorations.
5) Distalising the mandible to create palatal space for
anterior restorations.
6) Restoring a tooth which is involved in determing the
RCP.
7) Determining the magnitude and direction of the slide
from RCP to ICP in order to assess the resultant force
applied to anterior restorations.
8) Mandibular analysis in cases of facial assymetry,in
order to separate dental and skeletal causes.
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D)) Factors affecting Recording of the
RCP
1) Operator experience and training
2) The registeration material and recording
method employed.
3) The time of the recording
4) Guidance of the mandible
5) Neuromuscular conditioning
6) Record handling and storage
E)) RCP registeration media
• Waxes
• Zinc oxide pastes
• Acrylic resins
• Elastomeric materials
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Properties of ideal recording material
Demonstrate low initial viscosity
• Set rigidly
• Be dimensionally accurate and stable
• Be unaffected by disinfection protocols
• Be carefully handled and stored so as to avoid
distortion
F)) MANDIBULAR GUIDANCE AND
RCP
Aim: to help locate the condylar heads in the glenoid fossae at the
terminal hinge axis.
It can be either patient-guided or operator guided.
Yet, forceful mandibular retrusion by the operator can place the
condylar heads too inferiorly..and this leads to resistance of the
patient to the applied load .
Also, pain can occur from the
. operator’s guidance techniques
.the tmj
.muscle tension
Leading to reflex mandibular protrusion, and therefore erronous
recordings.
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G)) Different methods for recording RCP
Patient-guided Operator-guided
recording of RCP recording of RCP
1)Schuyler 1)Chin-point
Guidance
technique method 5)Anterior
guidance by a
2)Three finger tongue blade
2)Physiological
chin-point
technique guidance method 6)Anterior
Guidance by
3)Gothic arch 3)Bimanual a Leaf Gauge
(Arrow_point) manipulation
tracing method 7)Anterior
guidance by a OSU
4)Anterior Woelfel Gauge
4)Myo-monitor guidance by a
Lucia Jig 8)Power centric
registeration
method
Patient-Guided Techniques
1)Schuyler technique
This quick, simple technique involves the patient placing the tip
of the tongue to the back of the palate and closing into a
horseshoe of softened wax with light pressure.
Disadvantages:
1)There is no way of verifying
the nature of any unwanted
tooth contact or the retrusion of
the mandible.
2) The wax may not be uniformly
softened which can lead to
inaccuracies in the recording.
N.B
This technique can also be used on wax rims for the edentulous patient
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2) Physiological Technique:
Technique:
This method uses cones of soft wax placed posteriorly. The
patient swallows several times, simultaneously the mandible
retrudes and the recording is made.
Disadvantage:
There is no control over the mandibular retrusion ,nor over any
tooth contact.
N.B
Used mainly with edentulous patient.
3) Gothic Arch (Arrow-Point tracing)
•This technique is based on tracing the
movement of the mandible.
• Metal plates are added to the upper and lower
wax rims.
•The lower plate has a central pin, which can be
adjusted to the desired height.
•The patient practices mandibular excursions
using the device after which a fine spray of
Occlude (Pascal Co., USA) is added to the
maxillary plate.
•The patient then replicates the excursive
movements and the mandibular pin scribes an
arrowhead tracing on the maxillary plate
delineating the paths of these excursions.
•Where the three lines intersect indicates the
retruded mandibular relation.
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This arrangement can be set up for an extra-oral
registration following the same principles.
Disadvantages:
1) Relatively time-consuming
2) Requires well-defined, non-displaceable upper and lower
alveolar ridges to allow stable and retentive acrylic bases.
3) Large tongues can also cause base movement during the
tracing.
4) Truly reproducible excursive movements are often difficult to
re-create by patients thus producing an imperfect arrowhead
tracing .
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4) Myo-Monitor :
The myo-monitor is an electrical jaw muscle stimulating device
which is reputed to achieve muscle relaxation and produce a
neuromuscular mandibular position.
An example is the J-4 Muscle Stimulator (Myotronics-Noramed
Inc, USA) which produces pulsed ultra-low frequency stimulation of
facial and masticatory muscles.
Stimulating electrodes are placed over the coronoid notches and
a common electrode is located at the nape of the neck.
Proponents of the
myo-monitor suggest that
the ‘jaw-closer' muscles act
simultaneously, via reflex
contraction, to produce a
reproducible retruded
mandibular position.
Operator-Guided Recording of RCP
1)) Chin-point guidance Method
Technique:
1. The patient is seated upright and relaxed with the clinician positioned in front.
2. A softened two-layer wax wafer (1.4mm thick) is gently pushed against the cusps
of the maxillary teeth with just enough force to make slight cuspal indentations.
3. The wafer is removed, chilled and re-seated in
order to check fit and stability.
4. A registration medium is applied to the
mandibular surface of the wax wafer
5. The patient's mandible is guided into a hinge
closure by the thumb and index finger of the
operator, pushing on the chin.
6. After several smooth maneuvers of the mandible,
the hinge closure is completed until the mandibular
teeth just indent the registration material.
N.B The risk with this method is the ease with which the condyles can be over-
retruded.
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2)) Three-Finger Chin-Point Guidance Method :
This method is similar to the chin-point guidance method except
for the hand position of the operator.
A tripod is created at the chin-point and lower border of the
mandible on both sides by the thumb, index and third finger
Disadv.:
1.Care is required as this technique
might lead to deflection of the
mandible to one side.
2. This technique is not recommended
for edentulous subjects because the
operator's hand position can lead to
displacement of the lower denture
base.
3)) Bimanual Manipulation Method :
Technique:
It is carried out with the patient supine and the operator seated
directly behind.
The fifth finger of each hand is placed behind the angle of the
mandible, with the fourth fingers positioned just in front of the angle.
This permits the condyles to be directed anterosuperiorly within the
glenoid fossae
The third fingers are
placed on the inferior
surface of the body of the
mandible, and the index
fingers submentally in the
midline.
The thumbs are positioned
laterally to the symphysis
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By opening and closing a few times on the hinge axis the patient
will relax and the registration can be made.
N.B
This technique can also be used for the edentulous patient
assuming the lower alveolar ridge is developed enough to
allow the provision of a stable and retentive lower base.
4)) Anterior Guidance by a Lucia Jig :
•The basis of the Lucia jig method is to provide an anterior reference point, which
separates the posterior teeth.
• Thereby ,all proprioceptive reception from the teeth and musculature is removed .
Thus, the condyles can easily seat in the most anterior-superior position in the
glenoid fossae.
• The Lucia jig is made from self-curing acrylic resin on a study cast or in the mouth.
• At the dough stage, the acrylic resin is adapted to the upper anterior teeth, using
soft paraffin as a separator.
•The palatal acrylic is manipulated to just cover the palatal soft tissues.
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• The lingual aspect should slope posteriorly and superiorly at an angle of
between 40–60° and a wooden spatula can be useful in achieving this
•Once completed the jig is adjusted using articulating paper placed on
the palatal aspect whilst the patient performs lateral and antero-
posterior excursive movements.
•A selected lower incisor scribes an arrow-head pattern, the ‘wings' and
‘tail' of which can be ground away to leave the apex.
• This process is repeated until a raised area of acrylic at the apex
remains.
• This is the location of the retruded position .
N.B
1) It is important to note that while the jig is being adjusted out of the
mouth, the patient must bite on a cotton wool roll or a saliva ejector in
order to keep the teeth discluded otherwise the training effect of the jig
will be lost.
1) This method can also be used if upper anterior teeth are missing. The jig
is simply made to span the edentulous area and is adjusted in the same
manner.
5)) Anterior Guidance by a Tongue Blade :
The tongue blade method uses wooden spatulas instead of a
custom made Lucia jig to provide an anterior reference point.
The degree of tooth separation can be altered by the number
of spatulas used.
The patient's teeth must be discluded for a
period of time, usually between 10–20 minutes prior to
registration, in order for proprioceptive input
to be lost.
Once the correct anterior spatula guidance
is achieved, registration material is used to
record the relative position of the mandibular
and maxillary teeth.
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6)) Anterior Guidance by a Leaf Gauge :
It is considered as a variation from the lucia jig
technique.
It utilizes a pad of extremely thin acetate papers
that are autoclavable.
But now ,disposable paper versions are also
available.
The leaves provide the anterior reference point,
and the degree of tooth separation can be altered
until the teeth just achieve disclusion.
Then a registration of the posterior teeth can be
taken at that relation, using a bite registeration
material.
A registration support wafer may be used, to aid
in registration of the inter-dental record
7)) Anterior Guidance ba a OSU Woelfel Gauge
It is considered as a simplification of the
Lucia Jig Technique.
A specially designed device with a
graduated acetate bite platform is used.
The position of the bite platform is
adjusted antero-posteriorly until the teeth
are minimally out of contact.
A registration support wafer can then be
added and the inter-dental record taken .
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8)) Power-Centric Registeration method :
• In this technique, the mandible is not gently guided, it is subjected
to a directed force to achieve a retruded mandibular position.
•With the patient in a supine position, the dentist stands infront of
and to the right of him.
•The left thumb and forefinger are placed over the upper teeth. The
right thumb is placed on the superior aspect of the chin, while the
second and third fingers take position
along the inferior border of
the mandible. The operator's right
arm is stiffened and pressure is
applied from the shoulder by leaning.
It is suggested that reflex muscle shortening , is what causes
retrusion of the mandible in this technique.
Disadv.:
It is likely that the mandible is pushed too far posteriorly, thus
producing an error in RCP registration.
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