Calibrating Full-Arch Immediate Prosthetics with Condylar Centric in the Digital Era by Dr. Adam M. Hogan

by Dr. Adam M. Hogan

Introduction
Full-arch implant dentistry is rapidly becoming one of the most digitally dependent areas of modern practice. Yet for all the photogrammetry units, stackable guides, dynamic-guided surgery robots, and AI-driven design platforms emerging in our space, implementing the fundamentals of occlusion remains the responsibility of the human practitioner, with tools and skill sets rooted in analog dentistry. Final resting condylar centric relation (c-CR) position is paramount, along with vertical dimension of occlusion (VDO). VDO dictates function, aesthetics, phonetics, and biology. Albeit ironically debatable, c-CR, one of the most fundamental principles of modern dentistry, is vital to predictably stable full-arch outcomes.

The more digital our workflows evolve, the more relevant these principles become. Digital precision has exposed the inaccuracies, inconsistencies, and shortcuts leading to a mentality of “I’ll fix it later in the prosthetic phase.” Doctors develop habits of allowing for multiple 3D-printed revision prosthetics as they guess, hope, and stammer for an acceptable outcome. In the old world of analog workflow, this mentality would have forced all of them to quit their endeavors and return to the simpler practice of single-tooth dentistry. Analog workflow, with the type and frequency of mistakes now made digitally, would have been exorbitantly expensive and time-consuming. Still, digital errors and the dreaded “revision” set of teeth erode the profits and willpower a full-arch practice needs to thrive. More than ever, the digital era demands that we understand and implement condylar mechanics and vertical dimension with greater clarity.

This article examines why c-CR and VDO must be foundational in full-arch prosthetics in all phases: preoperative, intraoperative, and postoperative. It further examines how digital workflows can both simplify and complicate these classic prosthodontic principles, based on the knowledge and workflow application of the practicing dentist.


c-CR: The most misunderstood constant in full-arch dentistry
For purposes of clarification and emphasis, the author has retitled centric relation (CR) as condylar centric relation (c-CR). Why would this be necessary? The answer lies simply in the need to remind students and practitioners that CR is a condylar position and not a tooth position. Perusing journals and online forum content provides copious evidence that this simple principle is often overlooked, unstated, misstated, or simply mismanaged by even the most notorious and popular authors and educators.

Condylar CR is one of the most fundamental yet debated and misunderstood concepts in dentistry. If you were to ask 10 dentists to define c-CR, you may get 11 answers. Dentists and dental specialists often do not agree on the concept of c-CR because it sits at the intersection of biomechanics, philosophy, training bias, diagnostic ambiguity, and decades of conflicting literature. It is not that the joint position itself is impossible to define; it is that different disciplines define the purpose of CR differently, so they interpret its biomechanics through different lenses. But if one were to strip away the jargon and the politics of occlusion, CR becomes a simple, mechanical truth. In the modern era, centric relation is the most anterior-superior position of the condyle-disc complex, fully seated and braced against the articular eminence: a repeatable, ligament-guided position independent of tooth contact. In full-arch implant dentistry, tooth contact is irrelevant; therefore, CR becomes even more relevant.

The problem with definitions is the arbitrary nature of “how far anterior” the clinician describes the condyle. Some may believe in practices such as long centric or neuromuscular principles. But the reality is that full-arch implant dentistry requires a reproducible joint position because there are no periodontal ligaments to buffer mistakes. Full-arch prostheses resist micromovement, and the implants cannot adapt. The joint position therefore becomes the primary reference point and the sole malleable, compensatory anatomy in the reconstructed oral system.

When clinicians bypass c-CR, they create iatrogenic stress in the system, including, but not limited to, occlusal interferences, uneven loading, unbalanced bite complaints, early screw loosening, material fractures, midline shifts, and post-delivery TMJ symptoms. The diligent and competent dentist will determine the balanced c-CR before, during, and after surgery to minimize, if not eliminate, all complications related to the stomatognathic system.

Unfortunately, the haphazard, hopeful, poorly trained, and/or apathetic dentists and specialists who are over-reliant on digital technology and less reliant on proper education, training, and implementation of occlusion principles may not realize that digital articulation and technology are incapable of fixing improper jaw registrations. They may be surprised to discover that digital articulation only magnifies the errors, miscalculations, and mistakes.


c-CR matters even more in digital dentistry
Digital workflow relies on a consistent reference frame. Errors compound when jaw relation is off by even a fraction of a millimeter. Digital systems assume a stable hinge axis, a repeatable condylar position, a predictable arc of closure, and a defined VDO. The living human patient is anything but a predictable and defined digital hinge. If the practitioner submits records with incorrect condylar centric, VDO, or maxillomandibular relations, then every downstream step is not simply wrong but precisely wrong. The mistakes are exponentially evident. Digital dentistry is a mirror: It does not fix your technique, but rather reflects it.


VDO: The most powerful variable in full-arch aesthetics, form, and function
VDO is the single most influential variable in full-arch fixed prosthetics because it defines the entire prosthetic envelope both functionally and aesthetically. VDO determines how much restorative space exists between the bone and the occlusal plane, which directly affects framework thickness, connector height, zirconia integrity, tooth proportions, pink aesthetics, and hygiene access. Too little VDO leads to weak materials, bulky prostheses, collapsed facial appearance, and compromised phonetics. Too much VDO overstretches tissues, distorts aesthetics, increases muscle strain, and destabilizes occlusion. The patient’s facial proportions, smile design, lip support, incisal display, and overall aesthetic harmony are all governed by VDO.

Functionally, VDO dictates mandibular posture, TMJ loading, elevator muscle activity, excursive pathways, and the entire occlusal scheme. Because implants lack periodontal ligament proprioception, occlusion must be engineered with precision, and the chosen VDO must harmonize with centric relation to avoid overload, screw loosening, posterior strain, and long-term prosthetic failure. Phonetics, such as the S, F, and V sounds, depend on accurate VDO for proper tooth-to-lip relationships and normal speech patterns. Even airway stability and tongue posture are influenced by VDO, making it a vital factor in patient comfort and physiologic adaptation.

In edentulous, posterior-edentulous, and terminal dentition patients, and in those with dentate interferences, there is no reliable preexisting reference. In full-arch reconstruction, VDO influences everything: facial aesthetics, speech, function, biomechanics, and prosthetic design (see Table 1).

An incorrect VDO is instantly visible to even the untrained layperson. In any full-arch modality, from FP1 to FP3, VDO establishes the entire restorative envelope.

Vertical dimension is not a number; it is a biologic relationship that integrates aesthetics, biomechanics, speech, and patient comfort. In immediate full-arch reconstruction, every catastrophic mechanical complication traces back to an incorrect or untested VDO. The provisional phase becomes essential for validating this dimension before finalizing the prosthesis. When VDO is chosen and verified properly, it produces a stable occlusion, a durable prosthesis, natural aesthetics, and a highly satisfied patient.


The truth: You cannot ‘design your way out’ of a bad jaw relation
Many clinicians fall into the trap of believing that if the bite is incorrect, the laboratory can simply “fix it digitally.” This misconception overlooks a fundamental truth: Digital software is a replication tool, not a corrective one. A scanner or design platform can work only with the information it is given. If the interocclusal record is inaccurate, if the patient was guided into a false pseudo-centric relation, or if the condyles and articular disc were not properly seated, the software will reproduce those errors with horrifying yet exquisite precision. Digital articulation cannot compensate for a flawed jaw relation, an unstable hinge axis, or a vertical dimension chosen without careful facial and functional analysis.

Vertical dimension and centric relation are biologic realities, not digital constructs. If VDO is selected by guesswork rather than prosthodontic principles, or if the joint is not seated in a reproducible position, no amount of digital refinement can manufacture a stable occlusion. In fact, digital workflows often magnify these inaccuracies because their precision and built-in assumptions remove the “forgiveness” that analog systems once provided. A millimeter of error in the record becomes a millimeter of error in the design, the try-in, and the prosthesis itself.

The promise of digital dentistry is enhanced accuracy, but only when the foundational records are correct. High-resolution scanners, photogrammetry, and CAD software produce beautiful, clean data, yet they are entirely dependent on the clinician’s ability to establish proper jaw relationships beforehand. In full-arch prosthodontics, digital technology does not rescue poor fundamentals; it exposes them.


Digital dentistry gives us new tools but the same responsibilities
Digital workflows have dramatically improved our ability to record, transfer, and preserve VDO and c-CR, but only when these relationships are accurately diagnosed and established by the clinician. Photogrammetry can capture multi-unit implant positions with extraordinary precision, yet it tells us nothing about jaw relationships or occlusion.

Likewise, intraoral scanners eliminate many of the distortions inherent to analog impressions, but they cannot confirm whether the condyles are fully seated or whether the mandible is positioned in a compatible and stable c-CR.

Digital facebows and virtual articulators have replaced their mechanical counterparts, but they are only as accurate as the clinician’s inputs and assumptions. To be fair, neither the analog nor the digital articulator can replicate the human hinge, with its infinite permutations of possibility in the living stomatognathic system. The articulator has always been a hypothesis based on some degree of average human replication.

The long-standing phrase “garbage in, garbage out” is even more relevant in the digital age. Dentists have always known that a laboratory cannot fabricate a proper prosthesis from inaccurate analog records, and the stakes are higher with digital systems. When analog errors occurred, they were often masked or softened by manual steps in the workflow. The lab could adjust wax, reinterpret casts, or compensate for distortions instinctively. Digital workflows remove these compensatory layers. When the foundational records are wrong, CAD software reproduces the error with exacting fidelity, making the problem more obvious and more difficult to correct later in the process.

Digital dentistry does not eliminate the need for clinical skill; it amplifies it. Poor CR or VDO records are not “fixed” by scanning; they become embedded in a precise, immutable dataset that informs every subsequent step. Digital tools enhance accuracy, efficiency, and communication, but they do not replace the clinician’s responsibility to accurately diagnose joint position, verify condylar seating, and prescribe a stable VDO. The quality of the digital workflow will always reflect the quality of the fundamentals that precede it.

In clinical practice, it is necessary to determine the final desired VDO and c-CR, capture it, and convey it to the laboratory before smile and occlusion design. In this process, a new patient who presents to the office is first assessed and recorded. The technician collects data such as radiographs and intraoral and extraoral photographs, and then captures “denture quality” IOS scans of the maxillary and mandibular situations. The technician captures in vivo records as they are, in what the author calls the “situation IOS,” or “Situ” for short. Then, through careful prosthetic analysis, the clinician will diagnose and write a prescription for VDO, c-CR, and occlusion. To do so, the dentist must eliminate dental interferences to c-CR through enameloplasty or purposeful interocclusal opening when VDO is deficient. With the assistance of a combination of bite rims, putty, bite registrations, and/or a leaf gauge, the dentist captures the desired VDO. It is the dentist’s responsibility to diagnose, treatment plan, and capture c-CR at the desired VDO.

With the desired c-CR and VDO established, captured, and locked in, accurate digital records can be obtained. The record process continues with a CBCT, where the condyles are assessed to determine whether a credible, balanced relationship exists bilaterally between condyle and glenoid fossa. If the CBCT shows evidence of apparent c-CR, and if the patient’s lips can close comfortably and the face appears balanced in vertical thirds, looking full, supported, and relaxed, then the clinician can continue with digital records. Facial 3D scanning, photography, and IOS of the maxillomandibular relationship are captured at the final desired c-CR and VDO (see Table 2).

Evidence-based case example: Failure due to improper VDO and c-CR
Recently, a new patient presented to Full Implant Choice (Virginia Beach, Virginia) seeking a solution for a recurring and chronic five-year complication following full-arch immediate-load treatment. A periodontal specialist and a restorative dentist performed the original treatment.

Prior treatment included extraction of all remaining teeth, placement of six maxillary implants and five mandibular implants, and conversion to an analog immediate prosthesis. The final restoration consisted of a bar-supported PMMA prosthesis designed with what was, in the author’s opinion, an exaggerated “Hollywood-style” aesthetic. The patient was pleased with the grand appearance of the smile but unaware that complications may have arisen as a result of the robust tooth display.

The patient reported a history of repeated acrylic fractures, recurrent “bridge loosening” suggestive of screw instability, and persistent discomfort under her prosthesis and in the gums. Clinical and radiographic evaluation revealed complete failure of the two posterior maxillary implants on the left, with associated erythema and purulence (Figs. 1–4). Additionally, unbeknownst to the patient, the ailing mandibular implants exhibited crestal bone loss and left-sided tenderness (Figs. 5–7). Full reconstruction revision was deemed necessary, but the reason for this catastrophic failure had to be diagnosed first.

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The preoperative prosthetic records with digital workflow proved central to understanding the patient’s original failure. Through a combination of clinical history, CBCT analysis, and evaluation of coached c-CR, it became evident that the prior dentist had restored the patient with a violation of VDO. The condyles were not properly seated in the glenoid fossa. The patient’s history of repeated prosthetic fractures and screw complications supported the suspicion of a significant c-CR discrepancy compounded by excessive VDO. CBCT imaging confirmed translated and open condyles incapable of self-reduction. When the patient closed into the restored CO, the condyles were markedly translated and positioned inferiorly (Fig. 8). The diagnosis rendered was an excessive VDO with a nonphysiologic, unstable joint and disc position, and it would be necessary to reduce the vertical to stabilize the joint.

Fig. 8: Pre-operative evaluation of left condyle in preoperative CO.

Chairside, the clinician scanned the patient’s existing Situ IOS and collected photographs and a 3D digital facial scan to fabricate a 3D-printed provisional with a 2.5 mm reduction in VDO. Laboratory instructions were specific regarding selective reduction of both the maxillary and mandibular prostheses until an appropriate, harmonious VDO was reestablished based on facial proportions, aesthetics, and dynamic motion evaluation. Upon delivery of the provisional printed prosthesis, the patient immediately appeared more comfortable. She even noted that she felt more “at ease,” stating that she had never realized she was carrying tension for the previous five years until that moment. She was finally feeling reduced strain in the temporalis, masseter, and medial and lateral pterygoid muscles, and she was now able to achieve passive lip closure without activation of her orbicularis oris muscle.

After correction of the VDO through this diagnostic printed provisional prosthesis, the patient was guided into a stable c-CR position, and that position was captured with bite registration putty. With c-CR captured at a new VDO, the patient was scanned using a Carestream 9600 CBCT to evaluate the condylar position. The condyles appeared symmetrically and fully seated bilaterally, which validated the revised jaw relation. With joint stability confirmed, full digital records, including photogrammetry, 3D facial scanning, and intraoral scans, were submitted to JB Dental (Tempe, Arizona) for design, and all prosthetics were fabricated by Seven Cities Dental Arts, the in-house laboratory of Full Implant Choice.

In the surgical setting under deep general sedation, all old implants were removed, and new bilateral pterygoid implants, posterior-inferior zygomatic implants, and anterior implants engaging the nasal crest in the maxillary basal bone were placed. Postsurgical CBCT evaluation was performed for both implant assessment and confirmation of condylar position, which was verified bilaterally to be centered in the glenoid fossa (Figs. 9a–b).

Fig. 9a: Left condylar position after revision surgery.

Fig. 9b: Right condylar position after revision surgery.

The patient was successfully reconstructed at the correctly diagnosed c-CR and VDO (Fig. 10). This was accomplished only through meticulous presurgical and preprosthetic planning built on a stable, physiologic foundation. This case illustrates the critical importance of accurate jaw relations and vertical dimensions, not only for digital workflows but for long-term biomechanical success in full-arch reconstruction.

Fig. 10: Post-surgical CBCT showing implant distribution and temporization.

Conclusion: The future is digital, but the foundation is anatomy
It is imperative that the records submitted to the laboratory reflect the final VDO and condylar centric so the team can design and fabricate a functional, durable prosthesis with longevity. If the clinician controls condylar position and vertical dimension with discipline, then digital workflow produces a predictable prosthesis with a good prognosis. If not, then technology simply exposes the flaws that create complications. To become an expert, one must master the fundamentals of prosthetics before harnessing the digital and technological capabilities present in modern dentistry. With these old and new tools, the dentist may deliver the human transformation for the benefit of each individual patient in our care.

Full-arch implant dentistry is evolving faster than any discipline in our field. But no amount of intraoral scanning, photogrammetry, face scanning, or software replaces the careful capture of temporomandibular joint anatomy. Condylar centric relation and vertical dimension should not be forgotten prosthodontic relics with the advent of technology. Instead, foundational prosthetic principles are the pillars of modern digital full-arch dentistry. Digital workflows give us power, precision, and predictability, but only when our fundamental prosthetic diagnosis and treatment plan are correct.

References
1. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 8th ed. Mosby; 2020.
2. Lucia VO. A technique for recording centric relation. J Prosthet Dent. 1964;14(3):492-505.
3. Gilboa I, Cardash HS. Condylar position changes in centric relation before and after muscle self-training exercises. Int J Prosthodont. 2001;14(5):482-486.
4. Mongini F. The significance of condylar position in prosthetic treatment. J Prosthet Dent. 1977;38(6):563-573.
5. Abduo J, Lyons K. Clinical considerations for increasing occlusal vertical dimension: a review. Aust Dent J. 2012;57(1):2-10.
6. Sadowsky SJ. Occlusal considerations for implant prostheses in the edentulous patient. Int J Prosthodont. 2007;20(6):503-512.
7. Di Fiore A, Meneghello R, Graiff L, Savio G. Accuracy of digital interocclusal records: systematic review. J Prosthet Dent. 2020;124(2):161-167.
8. Mangano F, Gandolfi A, Luongo F, et al. Fully digital workflow for full-arch rehabilitation. J Dent. 2019;89:103193.
9. Wismeijer D, Joda T. Digital implant dentistry: review of clinical applications. Clin Oral Implants Res. 2019;30(S20):69-82.
10. Abdel-Azim T, Zandinejad A. Virtual articulators in prosthetic dentistry. J Prosthodont. 2015;24(2):120-125.
11. Joda T, Gallucci GO. The digital patient: virtual articulators for implant dentistry. Int J Oral Maxillofac Implants. 2015;30(5):1067-1073.
12. Mongini F. The role of the stomatognathic system in prosthetic treatment. J Prosthet Dent. 1977;38(6):563-573.
13. Ferrario VF, Sforza C. Mandibular kinematics and muscle activity under altered VDO. J Prosthet Dent. 1999;82(2):190-195.

Adam M. Hogan, FAGD, ABOI, USMC, is the owner of Full Implant Choice, a Virginia Beach practice dedicated exclusively to full-arch, fixed, immediate-load implant surgery and prosthetics. He also leads Seven Cities Dental Arts, an in-house digital laboratory, and The Atlantic Implant Institute, where he educates doctors and teams in full-arch surgery, digital workflow, and practice systems. Hogan is also host of the “All In All on X” podcast, featuring conversations on implant dentistry, leadership, business, and personal growth. A United States Marine and University of Michigan alumnus, he has performed full-arch “teeth-in-a-day” procedures since 2003. He is an honored fellow AAID, fellow AGD, and board-certified diplomate ABOI.