Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2011 38; 655–660
Occlusal measurement method can affect SEMG activity
during occlusion
S . E . F O R R E S T E R * , R . G . P R E S S W O O D †, A . C . T O Y ‡ & M . T . G . P A I N §
*Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK, †Gaylord, Houston, TX, USA,
‡
Gorse Covert Dental Practice, Loughborough and §School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
SUMMARY Occlusal indicators are widely used in
dental treatment to measure tooth contacts that
occur during occlusion. However, the presence of an
indicator may affect the mechanics of occlusion and
lead to invalid tooth contact data. The objective of
this study was to determine the effect of four
indicators (Parkell, silk, T-Scan sensor and paper)
on surface electromyography (SEMG) activity during
occlusion. Twenty-three subjects performed strong
bites and maximum clenches onto the four indica-
tors and natural dentition. Surface electromyogra-
phy recordings of anterior temporalis and superficial
masseter activity and the subjects’ perception of
each indicator were measured. SEMG activity with
the T-Scan sensor and paper was significantly
different (higher masseter activity; P < 0Æ05) com-
Introduction
During an occlusal examination, the accurate measure-
ment of tooth contacts can provide valuable informa-
tion for diagnostic, treatment or prognostic purposes
(1). Currently, this is achieved using occlusal indicators
(or ‘bite registration’ strips) that are important tools in
locating interferences and refining occlusal contacts
during prosthodontic treatments (2). A wide range of
indicators exist which can broadly be divided into two
categories based on their measurement capacity. Qual-
itative indicators, such as articulating paper and artic-
ulating silk, are limited in measurement to only the
location and number of tooth contacts. These are the
most commonly used indicators because of their low
cost and ease of application. Quantitative indicators,
including electro-optic and resistive techniques such as
ª 2011 Blackwell Publishing Ltd
pared to that for natural dentition. The Parkell
and silk gave no significant differences to natural
dentition. Similarly, subjects perceived that T-Scan
sensor and paper had the greatest effect on occlusion
and were the least comfortable (P < 0Æ05). Thus, the
very plastic T-Scan sensor and very thick articu-
lating paper both affected SEMG activity during
occlusion and, therefore, may not provide valid
tooth contact information for dental treatment. In
conclusion, occlusal indicators can change SEMG
activity during occlusion which may affect the
validity of the measurements they provide.
KEYWORDS: electromyography, masseter, temporalis,
maximum voluntary clench, jaw
Accepted for publication 8 January 2011
the T-Scan pressure measurement system, come with
the added capability of measuring the time and force
characteristics of tooth contacts but are more expensive.
The efficacy of occlusal indicators has been the
subject of numerous studies (1, 3–5). These have
mainly considered the accuracy, reliability and sensi-
tivity of the indicator in identifying occlusal contact
points (3–5). The main outcomes have been a criticism
of qualitative indicators for having poor reliability
because of the effects of moisture on the marking
process and of quantitative indicators for having poor
accuracy and sensitivity in the registration elements
(4). It has also been suggested that the presence of an
interocclusal material of finite thickness can result in an
over-detection of the occlusal contact area and bite
force for posterior teeth near the hinge axis (1) and that
indicator materials of excessive thickness can induce a
doi: 10.1111/j.1365-2842.2011.02205.x
656 S . E . F O R R E S T E R et al.
proprioreceptive response causing the jaw to deflect on
closing (2). Thus, there appears to be a genuine concern
that the introduction of an interocclusal material can
influence occlusion parameters and consequently the
tooth contact measurements, i.e. the tooth contacts
measured are not an accurate representation of the
tooth contacts that exist when no indicator is present.
Occlusal indicators differ not only in their marking
characteristics but also in material properties such as
thickness, plasticity and tensile strength. Hence, the
relevance of concerns relating to occlusal indicators
affecting tooth contact measurement is likely to vary
with indicator design. The objective of this study was to
determine whether four commonly used occlusal indi-
cators (Parkell, articulating silk, T-Scan sensor and
articulating paper; Table 1) affected surface electromy-
ography (SEMG) activity during occlusion. This was
achieved using SEMG to record muscle activity of the
temporalis anterior (TA) and superficial masseter (MS)
in healthy subjects during biting and clenching tasks
onto each indicator and onto natural dentition. If SEMG
activity during occlusion differed between an indicator
and natural dentition, then occlusion parameters and
tooth contact measurements may also be altered. The
selected media are either exposed to maximum clench-
ing under normal use or capable of being utilised in this
situation, e.g. Kerstein and Radke (6).
Materials and methods
Written informed consent was given by 23 volunteers
(14 males and 9 females, age, mean  standard devi-
ation = 29  9 years) with healthy jaw function.
Table 1. Details of the four occlusal indicators tested in this study
Indicator Abbreviation Manufacturer
AccuFilm PK Parkell Inc.,
II Red Edgewood, NY, USA
Articulating SK Hanel, Langenau,
silk Germany
T-Scan TS Tekscan Inc., Boston,
sensor MA, USA
Articulating PA Dentsply Int., New York,
paper PA, USA
Thickness measurements were obtained using a Sylvac d100s
plunger type capacitive absolute measuring probe (Sylvac, Criss-
ier, Switzerland) with accuracy of 0Æ1 lm.
Loughborough University ethical advisory committee
approved the study which was conducted in accordance
with the Declaration of Helsinki. Healthy jaw function
was defined as having no more than four teeth
removed, no audible clicking during normal jaw func-
tion and no history of jaw pain requiring medical
attention. Data collection took place at a dental surgery
with the indicators applied by the same registered
dental nurse throughout and using standard clinical
techniques. As the focus of this study was limited to the
effect of indicator material properties on SEMG activity,
the same application procedure was used for T-Scan
sensor as for the remaining three indicators (Fig. 1),
thus removing the possibility of the T-Scan hardware
system confounding the results.
Subjects initially performed a number of familiarisa-
tion trials which involved submaximal clenches onto
natural dentition. The main protocol always started
with trials onto natural dentition; thereafter, the order
of tests on the four indicators and a second set onto
natural dentition was randomised across subjects. Each
test consisted of three trials; in the first, subjects slowly
brought their teeth together to form a stable occlusion
and then performed a strong bite onto the indica-
tor ⁄ natural dentition, the second and third were
maximum clenches held for 3–5 s. Subjects performed
a bite onto cotton rolls between each indicator to give a
common starting point in terms of prior proprioception
and muscle activation. Subjects were fully briefed on
the experimental protocol, but were given no informa-
tion on the nature of each indicator.
Surface EMG were recorded at 2000 Hz bilaterally
from the TA and MS using an active bipolar surface
Thickness
(lm)
24
60
96
202
Fig. 1. Application device used for all indicators. Note that the
indicators were applied simultaneously to both sides of the mouth
following standard procedures.
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 OCCLUSAL MEASUREMENT CAN AFFECT SEMG ACTIVITY 657

electrode system* and stored for off-line analysis in articulating paper (P = 0Æ033) and similarly in APC for
Matlab†. The skin was cleaned using isopropyl wipes, T-Scan sensor (P = 0Æ050) and articulating paper
and rectangular pre-gelled disposable electrodes (P = 0Æ040) (Fig. 2). Parkell and articulating silk
(28 · 18 mm; Ag-AgCl‡) were applied to the muscle showed no significant differences in EMG parameters
belly, determined through palpation, parallel to the to natural dentition.
fibre direction with an inter-electrode distance of There was a significant indicator effect for MS
18 mm. The reference electrode was placed on the maximum activity (P = 0Æ026) and APC (P = 0Æ020).
forehead. All electrodes were secured using surgical Superficial masseter activity was higher for T-Scan
tape. The EMG signals were amplified at source using sensor and articulating paper compared to Parkell and
small custom-built amplifiers taped firmly to the skin articulating silk. A significant indicator effect was also
(gain setting, 3000; input impedance, 1012 W; band-
width, 10–1000 Hz; and CMRR better than 100 dB).
The signals were bandpass filtered at 10–600 Hz using
a fourth-order zero-lag Butterworth filter. EMG ampli-
(a)
tude was evaluated as a root mean square (RMS)
average over a 50-ms window. The RMS amplitudes
were then normalised to the global maximum RMS
amplitude recorded for that muscle in all trials on a per
subject basis. Maximum and mean amplitude and
anterior–posterior coefficient (APC) [a measure of total
MS activity compared to total TA activity; 7] were
obtained from the normalised signals over the duration
of muscle activity. All values were expressed as a per
cent; for the amplitudes, this relates to the value
relative to the global maximum value, and for APC,
100% indicates that the total TA and total MS activities
were exactly balanced throughout the occlusion.
A questionnaire was used to obtain a subjective
report on how the indicators felt during occlusion. After
each indicator had been applied, the subject was asked
to rate the indicator on its effect on bite, comfort,
texture and toughness on a seven point scale.
Indicator effects on EMG parameters were assessed
using repeated measures ANOVA with Bonferroni post (b)
hoc analysis. Comparisons to natural dentition were
conducted using paired samples t-tests. Indicator effects
in the questionnaire responses were tested based on
rankings and Freidman analysis. All statistical tests
assumed a significance level of P £ 0Æ05.

Results
In the comparison of each indicator to natural denti-
tion, significant differences were obtained in MS max-
imum activity for T-Scan sensor (P = 0Æ018) and
*Biovision, Wehrheim, Germany.
†
The MathWorks Inc., Natick, MA, USA.
‡
Bio-logic, Mundelein, IL, USA.
Fig. 2. (a) Maximum activity of the temporalis anterior and
superficial masseter and (b) anterior–posterior coefficient in the
contact and bite (C+B) and maximum clench (MC1 and MC2)
trials for each indicator and natural dentition. The graphs show
the mean  s.d., and significant differences between natural
dentition ( ) and an indicator (•) are marked ( ). See Table 1
for indicator abbreviations.

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658 S . E . F O R R E S T E R et al.
Fig. 3. Perception questionnaire results. The graph shows the
mean  s.d. ranking with significant differences between indica-
tors marked ( ). See Fig. 2 for the legend.
observed in the questionnaire results (P = 0Æ003–0Æ008)
between the same indicator pairs (Fig. 3).
Discussion
A number of different occlusal measurement methods
are currently used during prosthodontic treatments. The
requirements of a good method can be summarised as
follows: (i) accurate and reliable; (ii) sensitive to
changes in occlusion characteristics; and (iii) valid in
terms of not influencing the occlusion parameters and
hence tooth contacts measured. Previous studies have
already suggested that certain indicators do not meet the
first two of these requirements, e.g. Schelb et al. (8), Hsu
et al. (9) and Saraçoğlu and Özpinar (4). The present
study was related to the third of these requirements; if
SEMG activity during occlusion was altered by the
presence of an indicator (Parkell, silk, T-Scan sensor
and paper were tested), then the occlusion dynamics
and tooth contact measurements may also be altered.
It was found that two of the indicators tested affected
SEMG activity during occlusion and potentially the
occlusion parameters. The thickest indicator (articulat-
ing paper) and most plastic indicator (T-Scan sensor)
both significantly altered SEMG activity of the MS, but
not of the anterior temporalis, compared to occlusion
into natural dentition. In comparison, Parkell and silk
gave no significant differences to natural dentition,
supporting their validity in providing the same occlusion
parameters as the no indicator condition. Articulating
paper, and to a lesser extent T-Scan sensor, had a similar
influence on SEMG activity as occluding onto cotton rolls
(10, 11), which may lend further support to the altered
occlusion parameters. These observations are reinforced
by the between-indictors results, which also highlighted
the difference in SEMG activity between Parkell and silk
versus articulating paper and T-Scan sensor.
The differences in EMG parameters were supported
by the questionnaire results on the subjects’ percep-
tions of the four indicators. Articulating paper and
T-Scan sensor were perceived to have had a signifi-
cantly greater effect on the bite, to be less comfortable,
tougher and rougher compared to Parkell and silk.
Thus, it is clear that the development of an accurate,
reliable and valid means of measuring occlusal contact
characteristics remains an important challenge within
the area of prosthodontic and restorative dentistry.
For articulating paper, it is likely that the indicator
thickness was the major contributor to the observed
difference compared to natural dentition given that it
was over twice as thick (202 lm) as the remaining
indicators (Table 1). However, T-Scan sensor gave
very similar response to articulating paper despite being
far thinner (96 lm) and closer to articulating silk
(60 lm) in thickness, suggesting that it may have been
other material properties that caused the observed
response. T-Scan sensor is far more plastic than the
other indicators and also much stiffer in compression,
reducing its ability to conform to the occluded surface.
Hence, the validity of tooth contact registration appears
to be affected, not simply by indicator thickness but also
by several other material properties.
This study measured SEMG activity of the mastica-
tory muscles (MS and TA) during occlusion. Thereafter,
a relationship between occlusion parameters and mas-
ticatory muscles activity levels has been assumed in the
conclusions presented. The advantage of this approach
is the quantitative nature of the measurements. How-
ever, there is some debate on the use of EMG to assess
occlusal features. A recent review has suggested that
occlusal features can affect the electrical signal record-
ings of masticatory muscles (12). Indeed, significant
correlations between the electromyographic character-
istics of masticatory muscles (amplitude and duration of
the contractile activity) and the number of tooth
contacts in occlusion have been reported (13–15). This
supports the current approach and the assumption that
changes in surface EMG characteristics may indicate a
change in the occlusion parameters, e.g. Baba et al. (16)
and Ceneviz et al. (17).
There has been much debate on the efficacy of the
T-Scan sensor system for occlusal measurements.
Some researchers suggest that the T-Scan sensor
system is an essential tool for practitioners because of
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 OCCLUSAL MEASUREMENT CAN AFFECT SEMG ACTIVITY
the ease in occlusal examination and accurate temporal
analysis of the occlusion (18, 19). In contrast, poorer
accuracy and lower sensitivity (leading to fewer
contacts) compared to qualitative indicators have also
been reported (4, 9). The current results also suggest
limitations of the T-Scan sensor system in terms of the
material affecting SEMG activity during occlusion and
possibly the occlusion parameters. Furthermore, in this
study, the T-Scan sensor sensors were applied in a
similar manner to the remaining indicators examined
(Fig. 1), whereas in reality, the T-Scan sensor system
uses a U-shaped applicator which may further influ-
ence mandibular position. Although outwith the scope
of this study, the effect of the T-Scan hardware on
occlusion is worthy of further investigation.
Many parameters in addition to SEMG activity have
been reported to influence occlusal analysis results, e.g.
tooth mobility, saliva quality and quantity, tooth
morphology, type of occlusal surface, roughness and
stain type of the indicator material (8, 20). For example,
it has been found that for articulating paper, articulat-
ing silk and articulating foil their results are dependent
on the condition (wet or dry) of the teeth (4). Hence,
despite the positive findings reported here for Parkell
and articulating silk in that they do not influence SEMG
activity, care is still required in the application and
interpretation of these indicators.
In conclusion, thick and ⁄ or plastic occlusal indi-
cators, e.g. T-Scan sensor and articulating paper,
significantly affect SEMG activity during occlusion.
Therefore, these indicators may not represent valid
methods of measuring tooth contacts that occur in the
absence of the indictor ⁄ sensor. In comparison, thin
pliable indicators, e.g. Parkell and articulating silk, do
not affect SEMG activity and, in this regard, represent
more valid means of identifying tooth contacts.
These results, combined with those of previous studies
on the performance of occlusal indicators (4, 8, 9),
confirm that a number of parameters can affect the
ability of an occlusal indicator to accurately, reliably
and validly mark occlusal contacts, and hence, the
selection and application of an indicator to support
dental treatment requires careful consideration and
interpretation.
Acknowledgments
This research was funded by grants from the British
Society of Occlusal Studies and Mrs Marion E Mundy,
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659
Houston, Texas. The authors also acknowledge the
advice given by Alton Barbour (University of Denver)
in designing the perception questionnaire, Hayley Giles
RDN for chairside assistance and David Holland for
providing the T-Scan sensors.
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Correspondence: Stephanie Forrester, Wolfson School of Mechanical
and Manufacturing Engineering, Loughborough University, Lough-
borough, LE11 3TU, UK. E-mail: s.forrester@lboro.ac.uk
ª 2011 Blackwell Publishing Ltd