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Intraoral Gothic rch Tracing

SimpI Technique Por Determining VDO and Recording Centric
Relation Position For Complete Dentures

Barry Rubel, D.M.D.; Edward E. Hill, D.D.S., M.S.

Abstract
In order to orate optimum esthetios, funotion and phonetios in oomplete denture fabrioation, it is neoessary to record
aoourate maxillo-mandibuiar determinants of occlusion.
This requires clinical skill to establish an accurate, verifiable
and reproducible vertical dimension of occlusion (VDO)

ture occlusion that is functional, comfortable and balanced, it is

necessary to both determine a vertical dimension of occlusion that
is in harmony with the patient's musculature and to record a relatively repeatable jaw relation position.' Both tasks require a degree
of accuracy that may challenge the knowledge and skill of the average general dentist. The purpose of this paper is to review and
illustrate a very simple and efficient technique for accomplishing
these two important steps in complete denture fabrication.

and centric relation (CR). Correct vertical relation depends

upon a consideration of several factors, including muscle

Background

tone, inter-dental arch space and parallelism of the ridges.

An acceptable vertical dimension of occlusion (VDOthe distance

between the jaws when the teeth are in maximum intercuspation)
for a denture patient depends upon many factors. Muscle tone,
inter-arch space and parallelism of the ridges all play a role. An
excessive VDO may cause the patient to gag, clench or have chronic
soreness of the edentulous ridges, whereas an inadequate VDO will
reduce the patient's face height and make him or her look older. It
could also reduce chewing ability.
Numerous techniques have been offered in the dental literature to
establish a VDO for the denture patient (biting force,' facial measurements,' phonetics,^ swallowing,' etc.). All of these rely upon the professional judgment of the dentist, which continues to develop with
increasing clinical experience in fabricating complete dentures. Robert
Lytle (1964) advocated using an adjustable central bearing device (a
flat metal plate attached to the upper record base and a flat metal plate
with an adjustable screw attached to the lower record base) for VDO
determination, assisted by patient feedback based upon the patient's
neuromuscular perception of what amount of jaw separation felt correct. He emphasized that the inexperienced dentist who uses the rest
position as a starting point to establish VDO is greatly handicapped,
because denture patients vary considerably in their interocdusal rest

Any errors made while taking maxillo-mandibuiar jaw relation records will result in dentures that are uncomfortable
and, possibly, unwearable.
The application of a tracing mechanism such as the
Gothic arch tracer (a central bearing device) is a demonstrable method of determining centric relation. Intraoral
Gothic arch tracers provide the advantage of capturing
VDO and CR in an easy-to-use technique for practitioners.
Intraoral tracing (Gothic arch tracing) is a preferred method
of obtaining consistent positions of the mandible in motion
(retrusive, protrusive and lateral) at a comfortable VDO.
RESTORATIVE DENTISTS want to be able to provide their complete denture patients with prostheses that look natural, are
esthetically pleasing and provide optimum function within biomedical and acceptable dental parameters. In order to create den40 NYSDJ AUGUST/SEPTEMBER 2011

Dentai
Practice
Brokerage
frem Sea te
Shining Sea.

B
Figure 1 . Gothic arch tracing.

distance requirements and because "most patients have the ability to

recognize an improved or proper vertical relation of occlusion."''
The adjustable central stylus (screw) for an intraoral Gothic arch
tracing device allows patient involvement in the VDO determination
process as recommended by Lytle. As for any technique used to establish VDO, it should be re-evaluated after teeth are set to insure that
phonetic, esthetic and physiological requirements are met.
Centric relation (CR) position (a mandibular position where the
condyles are superior and medially braced) is thought to be a relatively
repeatable jaw position from which all opening and lateral mandibular
movements begin.' As such, recording centric relation position at an
acceptable VDO is a critical step in the fabrication of complete dentures.
The dental literature cites many philosophies and methodologies on
how to attain centric relation. Bimanual manipulation of the mandible,
chin point guidance and the use of an anterior jig have all been advocated for dentate patients; each has pros and cons.
For the edentulous patient, soft-tissue-supported record bases
must remain stable during jaw positioning. Not holding the record
bases while the patient's mandible is manipulated, having the patient
curl the tongue to the top of the mouth, or the dentist securing the
lower record base with his or her fingers while manipulating the
mandible all may influence the patient or allow shifting of the record
bases and lead to an incorrect CR record. The use of a central bearing
device helps hold both record bases in place while the patient's muscles place the condyles in a retruded position that is most physiologically favorable for that particular patient without external influence.
Early extraoral graphic recordings by Balkwill produced an
intersection of arcs caused by lateral translation of the right and left
condyles, which form an apex of what is known as the Gothic arch
tracing (Figure I).' Hardy designed an intraoral tracer and made a
depression with a round bur at the apex of the tracing to help him

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NYSDJ AUGUST/SEPTEMBER 2011

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Figure 2. Components ot intraoral tracer: recording plate: stylus and holding

plate: locking nut tor stylus (Y& M Maxillomandibular Recorder, Edmonds Dental
Prosthetics. Inc., Springfield MO).

repeatedly place the mandible in its most retruded position. The

central bearing point was kept in the depression while plaster was
injected to form a static record." Other dental pioneers, such as
Harper, Schiffman, Ellinger and Gysi, all utilized Cothic arch tracers
to help determine optimal jaw position and eliminate occlusal discrepancies for their patients."
Phillips (1927) stated that the apex of a Gothic arch tracing
visibly indicates the correct centric position.'' Kapur and Yurkstas
(1957) concluded that an intraoral tracing procedure was more
consistent for recording centric relation in complete denture prosthetics than extraoral tracing or wax registration procedures." A
study by Myers ( 1980) found no evidence to support the contention
that a dentist-assisted jaw relation is more reproducible than the
relation indicated by a Gothic arch apex.'"

Technique

Figure 3. Looking nut tightened on stylus positioned on maxillary occlusion rim.

Figure 4. Gothic arch tracing on aluminum plate positioned on mandibular

occlusion rim.

Figure 5. Divot or hole is placed at apex ot tracing to mark centric position.

42

NYSDJ AUGUST/SEPTEMBER 2011

Intraoral Gothic arch tracers provide all the advantages of their

early extraoral counterparts, but do so with far greater simplicity.
The technique for using both old style and newer Gothic arch tracers is the same and utilizes four very basic parts (Figure 2). First,
the maxillary occlusion rim is contoured for: a. facial; b. incisai
length; and c. occlusal plane. A metal plate holding an adjustable
stylus is then secured to the maxillary wax occlusion rim and
record base and a flat metal plate is attached to the mandibular
occlusion rim and record base. The point of the tracing stylus
should be at the intersection of the maxillary midline and an
imaginary line passing through the distal surface of the first bicuspids. The aluminum tracing plate is attached to the mandibular
record base and wax rim, so that it is parallel to the maxillary plate
and perpendicular to the tracing stylus.
The record bases are returned to the mouth and the stylus is
adjusted to allow a VDO position that feels comfortable to the
patient and appears esthetically and physiologically correct to the
dentist. A locking nut is used to secure the height of the stylus when
the VDO is acceptable (Figure 3). The patient is instructed to
retrude the jaw and then advance the mandible into a protrusive
position. These paths of retrusion and protrusion are repeated several times to ensure they are marked on the lower tracing plate
(Figure 4). Air abrasion of the tracing plate to give a matte finish or
coating with wax may make the tracing marks easier to see. The
patient is then instructed to carry his or her mandible into its most
lateral movements; these movements are similarly marked on the
lower tracing plate.
After a discernable Gothic arch tracing has been marked on
the aluminum plate, a small hole or divot is made with a #6 round
burr at the apex, which is used to position the patient for a static
record (Figure 5). The record bases are returned to the mouth and
the patient is asked to close his or her mouth and move to a
retruded mandibular position so that the stylus falls into the divot

or hole. Quick-setting plaster, or any other rigid material, may be

injected between the rims or placed on the rims to produce a
static record of centric relation position at the predetermined
VDO for the patient (Figure 6). After mounting casts on a suitable
articulator and setting the teeth, the wax trial dentures should be
evaluated for correctness of the chosen VDO and centric relation
occlusion (Figure 7).

Conclusion
The use of an intraoral Gothic arch tracing device is a simple, efficient and relatively consistent technique to determine both VDO
and record a repeatable retruded jaw relationship when fabricating
complete dentures.'"' It is a tried and tested technique that is not
new to dentistry, but may be especially useful for the younger dental practitioner or dentist with limited experience in treating completely edentulous patients.

Figure 6. Quick-set plaster used to secure plates in centric relation position.

Queries about this article can be sent to Dr. Rubel at brubel&umc.edu.

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Figure 7. Try-in after tooth set-up to confirm correctness of VDO and centric relation occlusion.

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