Managing CR-MIP discrepancies in clear aligner treatment
- Jesper Hatt DDS
- for 1 dag siden
- 8 min læsning
When planning clear aligner treatments for adult patients, discrepancies between Centric Relation (CR) and Maximum Intercuspation Position (MIP) are often overlooked - but they can significantly affect both functional stability and long-term success.
Understanding how to identify, diagnose, and manage CR-MIP discrepancies is essential for any dentist performing clear aligner treatment and caring about the patients functional occlusion (Not just the static occlusion). Failure to address these discrepancies can result in TMD symptoms, occlusal instability, mid-course revisions, or even relapse. This comprehensive guide explains why CR matters, how to approach clear aligner treatment planning, and how to avoid common mistakes in adult orthodontic care.
Understanding CR and MIP
Centric Relation (CR):
A repeatable, physiologic position where the condyles are seated in the most superior and anterior position within the temporomandibular fossa. This is independent of tooth contact and is considered a stable joint position.
Maximum Intercuspation Position (MIP):
The position where the teeth come into maximal contact, often influenced by dental wear, restorations, or tooth movement.
Discrepancies between CR and MIP can lead to uneven occlusion, hyperactive muscular activity, temporomandibular joint (TMJ) strain, and challenges in achieving a functional bite.
Clear aligners, with their precision and control, provide a powerful tool to address these issues effectively. But only if we have a distinct diagnose and know how to handle the related challenges.
Why Centric Relation matters in clear aligner treatment
When working with clear aligner treatment in adult patients, understanding and respecting the Centric Relation (CR) becomes even more important as it has a direct impact on the patietns functional occlusion. Clear aligner therapy moves teeth in all directions, but unless we consider the stability of the temporomandibular joints, we risk creating a visually pleasing result that lacks functional harmony.
CR as a stable foundation
Centric Relation represents a repeatable, physiologic position where the condyles are properly seated in the joint, independent of any tooth contact. This makes it an ideal reference point for diagnosis and treatment planning, especially when there’s a discrepancy between CR and MIP.
If you only plan your clear aligner treatment based on the patient's habitual occlusion (MIP), you might unknowingly move the teeth into a position that conflicts with the stable joint position. This can result in instability, functional issues, or even post-treatment relapse. Using CR as your reference ensures that your treatment goals are built on a stable foundation.
Reducing the risk of TMD complications
Misalignments between tooth position and joint stability may lead to temporomandibular disorders (TMD), causing symptoms such as joint clicking, muscle tenderness, headaches, or long-term discomfort. Incorporating CR into your assessment allows you to avoid inadvertently inducing joint strain during or after treatment.
Better control in complex adult cases
Many adult patients have adaptive occlusions caused by years of compensations related to joint position, tooth wear, or missing teeth. These compensations often mask underlying disharmonies that only become apparent when tooth positions change during aligner treatment. By identifying CR at the start, you are better equipped to plan vertical corrections, manage overjet and overbite relationships, balance midlines, and address crossbites with confidence.
Essential for combined restorative-orthodontic treatments
In our oppinion CR is always a really valuable starting position no matter what kind of orthodontic treatment you are planning. Because we work in 3D and affect all teeth (Some more than others).
CR is particularly important in interdisciplinary cases where orthodontic treatment is combined with restorative work. When vertical dimension and occlusal relationships are being re-established with crowns, veneers, or full-mouth rehabilitations, CR provides the reference point necessary to ensure both function in harmony with the patients biology and habits whereby it ensures longevity of the final treatment outcome.
Reproducible and clinically accessible
Fortunately, CR can be reliably registered in daily practice (most often) using simple tools such as Lucia jigs, leaf gauges, or bimanual manipulation. This gives both you, your restorative lab technician and your aligner technicians a stable and consistent reference throughout the treatment process. If you are unfamiliar with how to register CR, what factors may affect your registration and how to deal with these situations. I highly recommend you take a comprehensive hands-on course about functional occlusion to learn it. (Pankey, Dawson, Kois, Spear, are some of the most reknown places to learn about these principles)
In summary: If you don’t take joint stability into account, you may create beautiful tooth positions that are functionally unstable. This can lead to treatments that deviate considerably from your origintal treatment plan, resulting in time consuming and costly adjustments and frustrations.
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Steps to manage CR-MIP discrepancies in clear aligner treatments
1. Comprehensive Diagnosis
Begin with a detailed history and clinical examination. Look for symptoms like TMJ discomfort, clicking, or locking, sore muscles, asymetric muscle size, head and body posture, discrepancy between interarch position in CR and MIP as these may indicate joint instability.
Use tools like bite registrations, mounted models, or even digital jaw tracking systems to analyze the CR-MIP discrepancy.
2. Plan with Precision
Collaborate with your aligner treatment planning team or utilize services like AlignerService, where experts guide you through the nuances of treatment planning.
Ensure your treatment plan addresses the patient’s functional needs first. This might involve minor intrusion/extrusion or re-establishing proper anterior guidance.
3. Establish Joint Stability Before Moving Teeth
If the patient exhibits TMJ symptoms or significant discrepancies, consider stabilising the joints with a bite splint (e.g., a b-splint, Kois deprogrammer, Tanner appliance or the like) before initiating aligner therapy.
A stable joint position ensures that your aligner plan does not exacerbate underlying issues.
4. Adjust Occlusion Gradually
Aligners can be used to adjust the position of teeth to harmonize CR and MIP. Focus on small, controlled movements and monitor occlusal changes at each stage.
Use digital software to visualise and simulate the occlusion at the end of the treatment. You should however be aware that large discrepancies between CR and MIP may lead to challenges in the aligner software as no software on the market lets you mount your models reliably in a virtual articulator. This matters quite a lot as it requres you to visualise your desired end result in your head which you will have to transfer to a treatment plan, that will bring you closer to that envisioned result. In these kind of cases you should always expect (and plan for) at least one- but often several revisions.
Want to dive even deeper into mastering clear aligner treatment planning?
Our book Mastering Aligner Orthodontics offers step-by-step guidance on how to plan, troubleshoot, and execute clear aligner treatments, especially in complex cases where functional considerations like CR-MIP discrepancies play a key role.
Whether you work with SureSmile, Invisalign, ClearCorrect, or Spark, you’ll find practical workflows, real-world case examples, and system-specific tips that help you achieve stable, predictable results for your patients - both functionally and aesthetically.
5. Incorporating functional bite analysis in your workflow
Treatment planning software for aligners don't include tools for bite simulation.
A lot of the systems offer a bite jump simulation. However these bite jumps are simply a matter of the software putting the models of the teeth together in a way that makes the occlusion fit nicely. Which means it has nothing to do with reality.
Bite jumps may be used when treating children as they are often able to adapt to major CR-MIP discrepancies. But it is our expericence, that this rarely happens in adult patients... on the contrary.
The reason hardly any aligner company offers the integration of a virtual articulator is probably twofold:
There is a limited number of dentists being aware of how and why to use it. (i.e. there is a limited number of customers attracted to this kind of functionallity).
It is really difficult to work with an articulator in orthodontics as the reference points are constantly changing. In order to be useful it would require multiple registrations during treatment that would most likely not be performed as it adds limited value compared to the workaround (visualise the plan initially and adjust as you go).
In these cases it is really recommended to engage your patient in discussions about their occlusal situation, symptoms and involve them in the treatment goals. We encourage you to inform the patient up front about the fact, that it is hard to promise any set timeframe for treatment and why this is the case. This approach calibrates expectations and secures enhanced cooperation.
Key Tips for Success
Collaborate with Experts:
Working with an expert treatment planning service like AlignerService gives you access to orthodontic insights as well as functional occlusion in interdiciplinary ortho-restorative cases and ensures your treatment plan aligns with functional goals.
Educate Your Patients:
Explain the role of CR and MIP in their treatment to build trust. Patients are more likely to follow through when they understand the “why” behind your decisions and recommendations.
Monitor and Adapt:
Regularly evaluate progress during treatment. Mid-course corrections are most often necessary to refine the alignment and occlusion.
Case Example: A Success Story
A patient presented with a significant CR-MIP discrepancy and TMJ discomfort. After stabilising the joint with a functional appliance, we used clear aligners to gradually adjust the occlusion, focusing on re-establishing anterior- and canine guidance. By the end of treatment, the patient had a stable bite, improved TMJ health, and a beautiful smile. Even 10 years post-treatment the teeth looked almost exactly as the day the treatment was finished. This success was achieved by closely monitoring joint stability and leveraging expert treatment planning tools.
Final Thoughts
Working with clear aligners when there’s a CR-MIP discrepancy requires a thoughtful approach. By prioritising joint stability, planning with precision, and leveraging tools and expert services like AlignerService, you can achieve excellent clinical and aesthetic outcomes.
Need help planning complex aligner cases?
Contact AlignerService for expert aligner treatment planning that integrates functional occlusion principles for long-term stability.
For more insights on managing aligner treatments, stay tuned to our blog or reach out to us directly for guidance.
FAQ:
Q: What is the difference between CR and MIP in clear aligner treatment?
A: CR refers to the stable joint position where the condyles are seated, while MIP refers to the position where teeth have maximum contact. In many adult patients, these positions do not match, which can cause functional problems if not properly addressed during treatment planning.
Q: Can clear aligners fix CR-MIP discrepancies?
A: In many cases, yes — but only if the discrepancy is properly diagnosed and carefully planned. Aligners allow precise control over tooth movement, but joint stability must always be the primary reference.
Q: What risks are involved if CR-MIP discrepancies are not addressed? A: Potential risks include occlusal instability, joint pain (TMD), bite changes, muscle discomfort, and increased need for costly treatment revisions.
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Kind regards
Jesper Hatt DDS
P: +41 78 268 00 78
AlignerService
We are dentists helping dentists create realistic, safe and predictable treatment plans with clear aligners.
Currently more than1500 dental practices in 19 different countries use our service on a regular basis. We offer expert guidance in the following clear aligner systems: Invisalign, SureSmile, ClearCorrect, TrioClear, Angel Aligners and Spark.
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