Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

Prof. Somashekhar Nimbalkar

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Saraswati Dental College
On Sep 2018

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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
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Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : ZE01 - ZE07 Full Version

Techniques to Guide the Mandible to Centric Relation- A Systematic Review

Published: July 1, 2021 | DOI:
Sushma Ramaswamy, Abhijeet Ramachandra Kore, Pronob Kumar Sanyal, Anand Joshi, Siddhi Hathiwala, Prasad Nayan Tayade

1. Associate Professor, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India. 2. Associate Professor, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India. 3. Professor and Head, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Satara, Maharashtra, India. 4. Professor, Department of Physiology, Krishna Institute of Medical Sciences, KIMSDU, Satara, Maharashtra, India. 5. Associate Professor, Department of Public Health Dentistry, New Horizon Dental College and Research Institute, Bilaspur, Madhya Pradesh, India. 6. Postgraduate Student, Department of Prosthodontics, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India.

Correspondence Address :
Anand Joshi,
Krishna Institute of Medical Sciences, Karad, Maharashtra, India.


Introduction: Centric Relation (CR) is the only physiological position which is repeatable, recordable and reproducible for prosthodontic rehabilitation. A missed CR can give rise to faulty occlusal relationships leading to a life time of trauma to the temporomandibular joints. Literature has various methods outlined to locate and record the CR but it’s confusing as to which method is best suited to take the condyles into CR position. Hence, this systematic review was conducted to find an answer to this very question.

Aim: To find a reliable clinical technique to guide the mandible to a recordable, repeatable and reproducible CR position.

Materials and Methods: The present systematic review was conducted from July 2019 to October 2019 at School of Dental Sciences, KIMSDU, Maharashtra. A 20-year comprehensive literature review was undertaken aiming to arrive at a reliable and repeatable method to guide the mandible to CR following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) and Patient Intervention Comparison Outcome (PICO) guidelines to the highest possible extent. The research material was sifted through MEDLINE (PubMed)-{(“CR technique”) (MeSH terms) AND/OR (Retruded mandibular position”) (MeSH terms)}, Cochrane library “CR techniques” and Google Scholar “CR techniques OR Retruded mandibular position” search engines. Cochrane collaboration tool was used to assess the risk of bias for the Randomised Controlled Trial, Methodological I index for non RCTs (MINOR). Quality and strength of the existing evidence was appraised by both the authors through Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results: Online database search was conducted from January 1998 to September 2019 resulting in a total of 950 articles being shortlisted. Post-screenings, using the exclusion criteria, nine articles of the total articles were reviewed. These were reviewed individually by both the authors and discussed for various techniques to guide the mandible to CR. The ultimate outcome of the review was that the clinicians are required to fall back on time tested models, scientifically sound and technically correct and uncomplicated to execute methods which have proven to yield the most excellent outcomes at zero or minimal cost. One such method is undoubtedly Dawson’s Bimanual Technique. Bimanual technique in supine position coupled with a simple anterior deprogrammer has consistently resulted in a physiological CR position that is recordable, repeatable and reproducible.

Conclusion: The primary outcome of this systematic review is that Dawson’s bimanual manipulation technique is superior to other techniques; primarily when carried out in supine position.


Centric occlusion, Condyle, Retruded mandibular position, Temporomandibular joints

Being the only repeatable, reproducible and recordable position to fabricate prosthesis, CR has an irreducible clinical perspective (1). Clinically, this is the utmost accommodating and unstrained position of the mandible (2). The concept of CR can find its genesis in the need for a reproducible physiological mandibular position without inimical ramifications on the Temporomandibular Joint (TMJ) emanating into prosthodontic rehabilitation. CR is used as the outset for fabrication of complete dentures; full mouth rehabilitation cases either with implants or Fixed Dental Prosthesis (FDPs) or distal extension Cast Partial Dentures (CPDs) for occlusal restoration (2),(3). Further; a missed CR can result in erroneous restorations/ prosthesis leading to deficiency in prosthodontic treatment (4),(5). Since the inception of CR more than a century ago, various aspects related to it such as its definition, methods to register and materials to record CR have all seen constant change. Each of these has advocates and critics alike (6),(7),(8).

The most recent Glossary of Prosthodontic Terms (GPT 9) defines CR as “a maxillomandibular relationship, independent of tooth contact, in which the condyles articulate in the anterior-superior position against the posterior slopes of the articular eminences in this position, the mandible is restricted to a purely rotary movement; from this unstrained, physiologic, maxillo-mandibular relationship, the patient can make vertical, lateral or protrusive movements; it is a clinically useful, repeatable reference position’’(9). To state simply, it is a relationship of the maxilla to mandible in a horizontal plane or antero-posterior direction (10).

Techniques to guide the mandible to CR, the topic of this paper, have also seen a number of different expert views and experiments on the fruition and success of different approaches. Worth mentioning here are chin point guidance, swallowing, dawson’s bimanual technique, Tongue tip to palate etc., (6),(7),(8),(11). Many research projects have also been conducted to compare several of these techniques (4),(12),(13),(14),(15),(16),(17),(18),(19),(20),(21),(22),(23). Various techniques to guide the mandible to CR have also been described in textbooks (2),(3),(24). Unfortunately, none of them have been able to culminate on an evidence based single technique with acceptable levels of repeatability and reliability (4),(6),(7),(8),(13),(25). Hence, this systematic review has been taken up as an attempt to provide an evidence based answer to fill this lacuna.

Material and Methods

The present systematic review was performed spanning 20 years from January 1998 to September 2019 and reviewed from July 2019 to October 2019, the last search was done on 31st October 2019 at School of Dental Sciences, KIMSDU, Maharashtra following the PRISMA and Population, Intervention, Control and Outcomes (PICO) guidelines (26).

The review focussed mainly on finding a reliable technique/s to guide the mandible to CR position. The review has not been registered.

Research question: Questions relating to PICO were generated to systematically review the available literature. With regards to the study population (P), randomised controlled trials which considered healthy dentulous, partially edentulous, and completely edentulous patients with no clinical signs and symptoms of TMJ disorder and oro-facial abnormalities were included. To answer the other questions of PICO, clinical techniques to guide the mandible to CR (I), studies comparing two or more techniques to guide the mandible to CR (C) were considered. Repeatable, reproducible and recordable CR position was considered as the outcome (O).

Search strategy: The research material was sifted through MEDLINE (PubMed)-{(“Centric Relation technique”) (MeSH terms) AND/OR (Retruded mandibular position”) (MeSH terms)}, Cochrane library “Centric relation techniques” and Google Scholar “Centric relation techniques OR Retruded mandibular position” search engines.

The detailed systematic search strategy is presented in (Table/Fig 1).

The search yielded a total of 958 articles of which were 78 animals related and 39 duplicate studies were removed leaving a total of 833 for further screening. A total of 539 studies were dropped after studying their titles and abstracts as they did not fit the scope of this review leaving 294 for additional scrutiny.

Further down in the process, 285 articles were excluded based on the exclusion criteria. The PRISMA flow diagram for shortlisting the articles have been shown in (Table/Fig 2).

These nine studies were then methodically checked to avoid any probability of discrepancies creeping up at a later stage in the review (12),(14),(15),(16),(18),(23),(27),(28).

Once all and any uncertainties and doubts were laid to rest the actual systematic review was undertaken. Eligibility of the relevant articles to be included in the systematic review was verified independently by two authors of this study. Any disagreement was resolved over discussion with the third reviewer. The screening of the titles and abstracts were done to clarify whether or not the articles were fit for further reading. At the end, a thorough hand search of the selected articles was conducted and the articles which were missed out were added. Within each included study, the following items; name of the author/s, publication date, sample size, mandibular guiding techniques compared were recorded.

Risk of bias assessment: Cochrane collaboration tool was used to assess the risk of bias for the RCT’s and MINOR index for non RCT’s (29),(30). A statistical comparison of results and a meta-analysis was beyond the scope of this systematic review due to the diversity of the study population, sample size, study settings. The quality and strength of the existing evidence was appraised by both the authors through GRADE system (31).


The selected number of articles which finally fit into the parameters of the focal question were nine (Table/Fig 3). which describes the exhaustive rundown of the selected nine articles (12),(14),(15),(16),(17),(18),(23),(27),(28).

(Table/Fig 4) shows the risk of bias in the studies using Cochrane collaboration tool (12),(14),(15),(16),(17),(18),(23),(27),(28).


The present systematic review was designed to identify published articles comparing the diverse techniques for guiding the mandible to CR position. Nine articles included for this review were all original studies, done in a clinical setup, comparing two or more techniques to guide the mandible to CR position.

The patients recruited in all the studies were healthy individuals, without any TMJ disorders or deformities in oral and maxillofacial region. Of the nine selected articles, four articles studied edentulous patients while the other five articles did examination on dentulous patients. A total of 222 subjects had participated in these nine studies, of which 115 patients were entirely edentulous and 16 were partially edentulous; while remaining 91 were dentulous.

Watanabe Y loaded the horizontal position data on a personal computer with the help of sensors attached to the gothic arch tracing. CR position obtained with excursive mandibular movements and recorded with gothic arch tracing, bimanual manipulation and chin point guidance in both supine and upright positions. From this comparison, it was inferred that bimanual manipulation technique in supine position gave reliable and repeatable results (27). Comparable results were obtained in the study done by Keshvad A and Winstanley R where bimanual manipulation, chin point guidance with a jig and gothic arch tracing were compared. Bimanual manipulation was found to be a superior technique when used along with anterior jig in all three axis, while gothic arch tracing was the least repeatable (14).

The anterior deprogrammer is a flat plane occlusal splint with an anterior acrylic block designed to disocclude the posterior teeth. It eliminates the patient’s neuromuscular avoidance mechanism and helps him/her to acquire CR position without assistance. The use of the deprogrammer and the action of the elevator muscles allow seating of the condyles in an anterior-superior position (32). An anterior programming device helps separation of the posterior teeth immediately prior to CR record fabrication which helps in the patient “forgetting” the established protective reflexes. Cotton rolls, plastic leaf gauge, oral small device made of autopolymerising acrylic resin placed between the maxillary and mandibular anterior teeth can be used as an anterior deprogramming device (33). This results in an anterior stop that acts as a fulcrum which directs the force provided by the elevator muscles to seat the condyles in CR position. This coupled with the Dawson’s bilateral mandibular manipulation technique has shown to result in a greater mandibular displacement from the intercuspal position than with a CR record alone. It turns the rigid muscles of a ‘clencher’ to butter (33),(34),(35).

In the study done by Millet C et al., swallowing technique was used as a technique to record both vertical and horizontal jaw relation and was compared to bimanual manipulation technique. It was noted that swallowing provides an occlusal zone and not merely a single position and hence cannot be used as a reference position in sagittal plane to record the CR position (28).

In his study, McKee JR compared the position of condyles achieved by Dawson’s bimanual manipulation and masticatory muscle contraction against an anterior deprogrammer with the help of condylar position indicating device. Condylar position achieved by both the techniques against an anterior deprogrammer was the same, when there were no influences from occluding teeth (15).

Another study included in this systematic review compared inter-maxillary relationships with manual (chin point guidance), swallowing and bimanual methods by Alvarez MC et al., (23). There was no significant difference found between chin point guidance and bimanual manipulation. However; there was a significant inference that, when used in combination with anterior jig or leaf gauge, all methods guide the mandibular condyles to the CR position. Among the three techniques evaluated, it was found that swallowing technique was dependent on patient and could cause inaccurate position in presence of occlusal interference. Celar A et al., studied guided and unguided mandibular positions in asymptomatic patients. Bimanual manipulation was compared to unguided jaw closure with reference to spatial relationship of condyle positions, repeatability over time and operator influence. The Non Manipulated (NM) technique placed condyle about 0.6 mm (average) anterior and inferior to the position obtained by bimanual manipulation. The differences in position were within tolerance of biological system. Proper exercise and guidance to the patient prior to recording the centric position resulted in almost similar reproducibility in both the techniques (16).

Kandasamy S et al., assessed condylar position by Magnetic Resonance Imaging (MRI) after common bite registrations; centric occlusion, retruded CR and roth-power CR. The study failed to sustain the claim that certain bite registrations could accurately position the condyles in specific position in glenoid fossa (12). Kazanji M et al., at checking reproducibility of three different techniques: bimanual manipulation, swallowing and chin point guidance. All the three techniques gave acceptable results however; the bimanual manipulation technique gave the most repeatable and reproducible result (17).

Sushma R et al., in a recent study compared bimanual manipulation technique with a new copyrighted technique (wax ball orientation technique). The technique involved a modification of the record base wherein three orientation wax balls were fabricated on the record base; one behind the incisive papilla, the second one in line with the premolar region and the last one at the posterior border of the record base near the posterior palatal seal region in line with the second molars. Patients were trained initially and once they were comfortable with the technique, were asked to touch the tip of the tongue to posterior most orientation wax ball and close on the occlusal rims thus guiding the mandible to CR. The two techniques were compared based on timings required to record CR accuracy. It was found that both techniques recorded CR accurately with insignificant difference between the two techniques. Also, the wax ball orientation technique required significantly lesser time than the bimanual manipulation technique to record CR (18).

Bimanual manipulation technique: Among the nine studies included in this systematic review, 8 studies compared bimanual manipulation technique with one or two other techniques. This passive technique of recording CR was described by Long JH and then modified and popularized by Peter Dawson (36),(37). Bimanual manipulation is considered as an accurate and reliable method for placing condyle in glenoid fossa in CR position by many researchers (15),(18),(19). Further, some studies observed that this technique gave the most reproducible and repeatable results (8),(14),(23). The results of six studies reported in this systematic review concluded that bimanual manipulation technique was better than the other compared techniques.

In this technique, the dental chair is reclined and the patient’s head is cradled by the examiner. With the help of both thumbs on the chin and the fingers resting firmly on the inferior border of the mandible, downward pressure is exerted by the examiners thumb and upwards pressure on the fingers thereby manipulating the condyle-disk assembly in their fully seated positions in the mandibular fossae, after which the mandible is carefully hinged along the arc of terminal hinge closure (37). Dawson claims bilateral manipulation is the only appropriate method to position the mandible in CR. In one of his studies, it was established that more than 3000 dentists preferred bilateral manipulation technique (38).

This technique positions the mandible posteriorly while concurrently directing force supero-anteriorly on the condyles providing:

• A swift corroboration of correctness of the position.
• Alignment of condyle-disk assembly.
• Integrity of articular surfaces, all the while being quick and straightforward.

This goes on to show the pre eminence of this technique over the other jaw manipulation methods. Once the correct skills are acquired, the CR position can typically be located and verified within a few seconds, all the while giving the operator excellent control over jaw movement (37),(38).

Chin point guidance is a passive method of recording CR described by Ramfjord and Ashand, Ash and Ramfjord, and first reported in literature by McCollum BB (39). Previously, it was also called as “3 Finger” method as the thumb, index finger and middle finger were all placed on the chin and the mandible was pushed as far posterior as possible. The method was then modified with the thumb placed on the middle of chin and the other two fingers supporting the mandible inferiorly (14). According to Keshavd A and Winstanley RB, Alvarez MC et al., Watanabe Y, chin point guidance technique could be used for recording CR with almost similar accuracy as that of bimanual method (14),(23),(27).

Swallowing is an active method of guiding the mandible to CR (40). Niswonger mentioned that during swallowing mandible travels from rest position to CR and back to the rest position (6). Kurth LE used the swallowing reflex in determining CR (22). Swallowing or free closure technique was advocated by Shanhan TEJ (41). While some authors advocate the swallowing technique for recording CR, few others state that CR differs from a swallowing position (6),(41),(42),(43). Numerous studies conclude that while swallowing the mandible never moves back to the terminal hinge position but remain slightly anterior to it (23),(31),(44),(45). Conversely, a minority of studies question the applicability of the swallowing technique for guiding the mandible to CR principally because of the various results it produces (3),(23),(28).

Gothic arch technique: Gothic arch technique was used in two of the studies done by Keshavd A and Winstanley RB and Watanabe Y (14),(27). Arrow point tracing or needle-point tracing or gothic arch tracing is an active method of guiding mandible to CR and was first introduced and popularised by Gysi (6). Gysi developed this method as an extraoral tracing technique which was later modified by Gerber et al., to an intraoral technique both having their own advantages and disadvantages. In this technique, the CR registration was not considered correct until the apex of the tracing was sharp and thin (40).

Power centric bite registration by Roth RH otherwise known as the Roth power technique is “a two-piece wax registration method”. It is understood to place the condyle in the optimal anterior superior CR position. In this technique patient’s own musculature is utilised to guide the mandible into CR when resistance is applied in the anterior region (46). It is recorded with a 2- piece wax registration consisting of anterior and posterior sections. The anterior section is first constructed at a vertical vis-à-vis the posterior teeth, at least 2 mm apart. This piece of wax is frozen and allowed to harden. The wax is then placed back into the mouth after which a softened posterior section is positioned, and the patient is instructed to bite. The mandibular anterior teeth are guided into the toughened anterior section of wax without a slide in the indentations. As the patient closes onto the hardened anterior section, he or she is instructed to “close firmly and clutch.” When the posterior section which is chilled with air hardens sufficiently to prevent distortion, both wax sections are then removed and chilled (47).

Active vs Passive techniques (Table/Fig 5): According to some researchers, active (unguided) method of guiding mandible to CR is superior to passive (guided) method. However; the supporters of passive method agree that pressure for guiding the mandible should not be heavy as it causes discomfort to the patients resulting in muscular activity for self-protection leading to protrusion of lower jaw (6),(20),(21). On the contrary, the articles reviewed in this systematic review observed that the most repeatable technique to record CR is bimanual manipulation which is a passive method.

Strength of this systematic review: This systematic review addresses one of the most contentious topics in dentistry in general and prosthodontics in particular. In spite of the availability of rich literature, there always has been a pertinent question as to which is the best method to guide the mandible to CR. This review addresses that question using the PICO format. The data extraction was charted out clearly and performed independently by two authors and any discrepancy found was resolved by consulting the third author. Though the general consensus seems to direct the choice of technique on numerous factors such as clinician’s judgement, expertise, experience and patient related factors, this review points at one particular evidence-based technique being far more superior to others considering the repeatability, reliability and outcome.


Firstly, the time frame selected for this systematic review was pretty long i.e. 20 years while only 9 articles could be selected for the review after the application of all the required criteria.The other limitation of the study was that a meta-analysis could not be conducted because of variations in the study population, sample size, study settings. Also, the number of patients allocated in each study was less for application on a large population. Hence, there is a scope to study the different technique to prove the superiority on a large population.


The primary outcome of this systematic review is that Dawson’s bimanual manipulation technique is better than other techniques especially when carried out in supine position. Irrespective of the technique used to guide the mandible to CR, clinicians should prefer supine position over an upright position. Muscle deprogramming with anterior jig or leaf gauge before guiding the mandible to CR gives superior results. At the bleeding edge of technology, the science of dentistry is being shaped and reshaped at a break neck speed and Prosthodontics is no exception. Innovations in diagnostics, advances in material sciences, and sophistication in biomedical engineering has ushered in a new dawn in the field of dentistry. The nascent stages of some of these advancements also bring in the burden of elevated costs for both clinicians and patients. Some developments stay prohibitively expensive for a long time for them to be accepted as a part of main stream treatment methodology, especially so in the developing and under developed countries.


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Date of Submission: Apr 07, 2021
Date of Peer Review: May 04, 2021
Date of Acceptance: May 27, 2021
Date of Publishing: Jul 01, 2021

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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