Académique Documents
Professionnel Documents
Culture Documents
Numerous authors and textbooks have advocated the concept of bilateral simultaneous occlusal contacts
as one of the necessary components of an optimum occlusal condition. All occluding surfaces should meet
at the same moment of time during a mandibular closure. Articulating paper labeling that appeared widely
distributed throughout the arch was thought to represent this advocated occlusal condition. However, com-
puterized occlusal analysis shows that true bilateral occlusal contact time simultaneity is not accurately
represented by widespread paper labeling. Articulating paper labeling is an inadequate indicator of per-
ceived occlusal contact time simultaneity as it renders no occlusal contact force or time sequencing. When
occlusal adjustments are guided by computerized occlusal analysis, occlusal contacts on all potentially
occluding teeth can be approximated to occur within .2 second. This technique report describes a clinical
procedure that employs computerized occlusal analysis to guide sequential occlusal adjustments to obtain
measurable bilateral occlusal contact simultaneity Additionally, the phenomenon of how articulator paper
labeling can be a misleading indicator of occlusal contact timing and force content is presented.
(Quintessence Int 2001:32:7-18)
Key words: bilateral simultaneous occlusal contacts, center of force (COF) trajectory, computerized
analysis, paper labeling, timed sequence
umerous authors and textbooks have advocated without the aid of computer analysis to illustrate the
N the concept of bilateral simultaneous occlusal
contacts^-^ as one of the necessary components of an
sequence and duration of individual tooth contacts.
In this report, clinical observation of computer-ana-
optimum occlusal condition. All occluding surfaces of lyzed occlusal contact sequences recorded from teeth
opposing maxillary and mandibular teeth should make with widespread articulating paper labeling present on
occlusal contact simultaneously. all occluding surfaces, reveals that widespread paper
Articulating paper labeling widely distributed labeling does not represent bilateral simultaneous
throughout the arch was thought to represent this occlusal contacts. Because articulating paper lacks
ideal condition. Similar color intensity labeling, which quantitative time- and force-descriptive capacity, it is
was present on all occluding surfaces combined with a incapable of measuring tooth contact events. Therefore,
"hollow shell" sound from a himanually manipulated^ its appearance should not be interpreted as a measure
centric relation occlusal contact pattern were thought of tooth contact time simultaneity or force content.
to indicate contact simultaneity. Conversely, the real-time recording capability of the
True occlusal contact time simultaneity, by defini- T Scan II Occlusal Analysis System (Tekscan) can
tion, means that zero seconds of time passes between record a given occlusal contact sequence in .01-sec-
the first and last occlusal contact. This, in actuality, is ond increments. The duration of time in which teeth
extremely difficult to achieve when performing occlusal make occlusal contact, as contacts proceed from first
adjustments, and is a virtually impossible clinical reality contact through to maximum intercuspation, can be
recorded and visualized. Using the occlusal contact
sequence as a guide for corrective occlusal adjust-
ments improves the operator's ability to create a mea-
'Assistant Clinical Professor of Fixed and Removable Prosthodontics, Tufts surable, bilateral simultaneous contact sequence.
University School of Dental Medicine, Department of Restorative Dentistry, This report describes a clinical technique that uti-
Boston, Massachusetts.
lizes computerized occlusal analysis of occlusal con-
^Lecturer at the Center for Advanced Dental Education, St. Petersburg,
tact time and force information to guide the occlusal
Florida.
Reprint requests: Robert B. Kerstein, DMD, 665 Beacon St. #204, Boston,
adjustments of a mandibular closure to obtain true
Massachusetts 02215. E-mail:Tmjdoc@IX.Netcom.com and measurable bilateral occlusal contact simultaneity.
Quintessence International
• Kerstein/Grundset
LITERATURE REVIEW contact force and time data. This statement was in
agreement with other authors who have reported valu-
In the middle to late 1980s, there was a series of pub- able diagnostic capability of the T Scan system.'"•-''
lished articles that reported that thefirstT Scan I system
was difficult to use clinically, and its recording sensor
yielded unreliable tooth contact location data. It was T SCAN II OCCLUSAL ANALYSIS SYSTEM
reported by Patyk et al,-" Yamamura and Takahashi,^ and
Harvey et al'' that the T Scan sensor and graphical inter- T Scan II is a Microsoft Windows (Microsoft) com-
face gave varying tooth contact location representations pliant system that has been integrated into a clinical,
from one recording to the next. The sensor was deemed diagnostic computer workstation. An IBM compatible
inflexible,"* illustrated a lack of sensibility on some of its PC, a Pentium processor, and a minimum of 4 to 8
recording surface area,^ and failed to reliably reproduce megabytes of RAM are required to properly operate
tooth contact location after 2 uses.^ Specifically the system. The graphic interface uses familiar
described was the inflexibility of an intraoral recording Windows toolbar icons to display the software fea-
device that was found to result in occasional mandibu- tures that are utilized to analyze occlusal contact
lar shifting during closure that rendered the tooth con- information.''
tact location data unreliable.'' Real-time recording is accomplished by measuring
Conversely, other authors found consistent measur- the recorded tooth contact events for their actual
ing capacity when analyzing time data'^ and reported elapsed time at a rate of 80 Hz (80 times/sec). By re-
clinical reliability in data analysis. Kerstein, in 1997, cording a force movie^* of a guided mandibular closure
reported statistically significant comparable multiple into centric relation, or self closure into maximum
daily disclusion time measurements for individual sub- intercuspation, the sequential tooth contact order and
jects and subject group mean values. These disclusion duration is captured in .01-second increments.
time means were reproduced on 4 to 5 distinct mea- The incremental playback of the tooth contact time
surement dates, and were statistically consistent can illustrate the exact order of tooth contacts, as well
between subjects, within individual subjects, and as their force content. The combination of contact
across subject groups.^ Kerstein also reported reliable order, contact duration that precedes the next occlusal
disclusion time means using the T Scan I sensor in contact, contact location within the arch, and contact
1991. Both pre- and post-treatment disclusion time force content all determine the degree of simultaneity
means for 7 female myofascial pain dysfunction syn- present in a particular occlusal scheme.
drome (MPDS) patients were statistically reliable.'" By making corrective occlusal adjustments that are
Recently, 3 studies accomplished by Sequeros et guided by successive computer recordings and by
al^^"'' have illustrated that consistent force and con- studying relative occlusal contact time changes that
tact location data can be obtained with the newer T result from these occlusal adjustments, the operator
Scan II sensor. These studies analyzed tooth contact can establish an occlusal scheme that contains true
location reproducibility in maximum intercuspation," time simultaneity (occlusal contact sequence
the number of tooth contacts reproduced in maxi- approaching .2 second duration or less). The resultant
mum, intercuspation, protrusion, and right and left lat- contact sequence displays a high degree of right side
erotrusion,i2 a^j tooth contact time reproducibility of to left side force balance (approximately 50% right to
tooth contacts in maximum intercuspation.'^ All 3 50% left), as both halves of the dental arch add
studies concluded that the newer T Scan II sensor sequential contacts equally.
could be utilized at least 4 times and reliably match
differing bites recorded from the same subject. This
finding is twice the usage reported by Harvey et al CENTER OF FORCE TRAJECTORY FEATURE
who reported that the sensor failed to be reliable after
2 uses. All 3 studies recorded at least 8 trials per sen- The COF (Center of Force) Trajectory'« software fea-
sor, to gather significantly more data than Harvey ture displays the history of the path of the center of
reported.^ One study reported a sensor precision level force from the beginning of the force movie recording
of 90% to 93% reliability through 4 uses.'^ However, to the current displayed frame. The movement of the
in another of the studies, the time analysis differed COF trajectory can be observed by playing a force
slightly from the force analysis in the reproduction of movie one frame at a time (.01-second incremental
the number of tooth contacts.'^ playback) with the COF trajectory selected from the
These authors reported that the T Scan is a simple tool bar. The trajectory is represented on the computer
methodology to measure and reproduce tooth contact screen by a red and white line that trails the COF
positions, while simultaneously quantifying occlusal marker (Figs 1 and 2).
T-Scan II - Reallime2
Eile Edil View ûptions Movie Jools Window Help
Fig 1 T Scan II tool bar with Center of Force Trajectory button selected.
Quintessence International
• Kerstein/Grundset
Fig 3a Force plot illustrating COF trajectory of the earliest con- Fig 3b Force plot illustrating progression of the COF trajectory of
tacts of a non-simultaneous mandibular closure into static inter- the same nonsimultaneous mandibular closure at .388 second.
cuspation at .280 second.
Fig 3c Force plot Illustrating the oompleted COF trajectory at Fig 3d Force plot at .519 second: the COF trajectory moves out
.469 second, to the right.
Figs 3f and 3g The Accufilm labeling of the closure in Figs 3a to 3e appears to indicate that all of the
teeth are bilaterally occluding at the same time. The true sequence is not observable with paper labeling.
y ^ »
Fig 4a Force plot illustrating COF trajectory of the earliest con- Fig 4b Force plot illustrating COF trajectory of the progressing
tacts of a simultaneous mandibular closure into static intercuspa- occlusal contacts of a simuitaneous mandibular closure into static
tion at .185 seccnd. intercuspation at .235 second.
Quintessence International 11
Kerslein/Grundset
Left side
— t_
60
40 — i'y
20
_—- ' •
Fig 7 T Scan II tool bar illustrating the location of the "1 frame-at-a-time forwards" button.
In order to locate the earliest contacts, the mouse time playback should be continued until complete sta-
should be placed into the graph where the maximum tic intercuspation has been reached (Fig 8). Static
force line begins to rise from the graph horizontal intercuspation is represented within the graph where
baseline, and the left mouse button should be clicked. the red and green lines become horizontal.
This will move the time line to the time in the contact In Fig 6, the earliest contacts that drag the COF tra-
sequence where the earliest contacts have been jectory out of the palatal midline are in the right cen-
recorded (Fig 6). The force plot displays the point in tral incisor, canine, and the first and second molar
the force movie that is located just before the earliest area. These contacts need force and time reductions in
contacts have been recorded. order to allow similar time and force loading of the
Next, the force movie should be advanced 1 frame left side. By adjusting these areas, the trajectory icon
at a time (.01-second increments) by placing the mouse will begin to track closer to the midline.
over the appropriate playback button on the tool bar The articulating paper labeling seen in Figs 9a and 9b
(Fig 7) and clicking the left mouse button once. As represents the posterior quadrant contacts. It describes
each successive frame is displayed, the COF trajectory the end point contacts that are the summation of the
will move in the direction of the earliest, most forceful, earliest contacts and those that follow through static
and most prolonged tooth contacts. The 1-frame-at-a- intercuspation until maximum intercuspation is reached.
Ouintessence International 13
Kerstein/Grundset
Left side
60 • -i 1
40 _ 1—. -. -^
20
\
0.0 0.5 1.0 1.5 2.0
Fig 9a The articulating paper labeling of Fig 9b The articulating paper labeling of
the right posterior quadrant. the left posterior quadrant.
Quintessence International 15
Kerstein/Grundset
Left side
80
60 -''1 K- • / '
40 —^••J 1
20
\:
00 0.5 1.0 1.5 '
Fig 11 Trajectory after 2 adjustment sequences. Fig 12 Trajectory after 4 adjustment sequences.
0.0
V forceful.
0.5 1.0 .5
A possible explanation for this inverse relationship
between the size of contact and its force content is that
the applied pressure of the occlusal force is measured
Fig 13 Force vs. time graph of simultaneous contact sequence relative to its surface area such that:
seen in Figs 4a to 4c.
Pressure^ Applied Force
Surface Area
Broad contacts dissipate force over a large area
Another erroneous assumption made regarding resulting in low pressure concentrations, whereas, a
paper labeling is that size and color intensity small contact will dissipate occlusal force over a small
describes forceful contact, A broad contact that is area. The smaller the surface area that receives a given
dark colored is perceived to mean a forceful contact. force, the more pressure results. Computer analysis
Compare Fig 3e with Fig 9a with respect to the may reveal that our profession has been misreading
palatal aspect of tooth 17, the size of paper labeling by reading it inversely. Large
In Fig 9a, there is very small red labeling illustrat- or broad is representative of low pressure, while small
ing a contact present on that incline. It appears to be represents high pressure.
Figs 14a to 14c Accutilm labeling of the contact sequence seen in Figs 4a to 4c of the maxil-
lary arch, (b) Right posterior quadrant, (c) Left posterior quadrant.
The only data that appear to be obtainable with Presently, there are no known occlusal time para-
articulating paper labeling are occlusal contact location meters regarding optimal closure timing. There are,
and surface area. Color intensity, size of labeling, and however, a number of studies regarding disclusion
microscratch labeling reveal the presence of an time^'"''^'' (the opposite of occlusion) that suggest
occlusal contact without revealing any description of that muscle function is dramatically improved when
the force content or time sequence data. Paper can disclusion time (the time required for posterior teeth
label the time as premature and forceful for occlusal to completely disclude in a mandibular excursion)
contacts that are isolated by computer analysis. The can be achieved in a less-than-.4-second excursive
combination of these 2 diftering mediums can guide the commencement through to solely anterior guidance
occlusal adjustment procedure to result in a measur- surfaces in contact. These studies imply that the faster
able bilateral simultaneous occlusal contact sequence. the patient comes out of occlusal contact, the less
Quintessence International 17
Kerstein/Grundset
contractile muscle activity is required to perform the 4. Patyk A, Lotzmann U, Scherer C, Lobes LW. Comparative
excursion. It is logical that the reverse occlusal action analytic occlusal study of clinical use of the T Scan system.
ZWR 1989;98:752.
would benefit in a similar manner. Therefore, a short
5. Yamamura M, Takahashi A. A study on display and accuracy
"occlusal time" should require less contractile muscle of occlusal contacts by means of T scan system. Kanagawa
activity than a prolonged occlusion time. Shigaku 1990;25:236.
Additionally, with true time simultaneity in 6. Harvey WL, Hatch RA, Osborne JW. Computerized occlusal
mandibular closure (< .2 second to complete closure), analysis: An evaluation of the sensors. J Prosthet Dent 1991;
there appears to be bilateral force distribution that 65:89.
distributes occlusal forces over both halves of the 7 Maness WL, Podoloff R. Distribution of occlusal contacts in
dental arch so that the muscular contractions are maximum intercuspation. J Prosthet Dent 1989;62:238.
more equally shared. The authors of this report note, 8. Reza Moini M, Neff PA. Reproducibility of occlusal con-
tacts utilizing a computerized instrument. Quintessence Int
however, that this premise needs to be tested scientifi- 1991;22:357-360.
cally to validate the clinical .significance of the short- 9. Kerstein RB, Chapman R, Klein M. A comparison of ICAGD
est possible occlusion time. (Immediate Complete Anterior Guidance Development) to
Clinical anecdotal observation by this author over "mock ICAGD" for symptom reductions in chronic myo-
the past 15 years has revealed that patients can "feel" fascial pain dysfunction patients. Cranio 1997;15:21-37
the difference between apparent paper labeling simul- 10. Kerstein RB, Wright N. An electromyographic and com-
taneous contacts and true and measurable simultane- puter analysis of patients suffering from chronic myofascial
pain dysfunction syndrome; pre and post-treatment with
ous contacts. A more "solid widespread contact sen- immediate complete anterior guidance development.
sation" is predictably reported when computer-aided J Prosthet Dent 1991;66:677-686.
simultaneity is achieved. 11. Sequeros OG, Garrido-Garcia VC, Cartagena AG. Study of
occlusal contact variability within individuals in a position
of maximum intercuspation using the T Scan system. J Oral
CONCLUSION Rehabil 1997;24:287-290.
12. Cartagena AG, Sequeros OG, Garrido-Garcia VC. Analysis
of two methods for occlusal contact registration with the T
By employing computerized occlusal analysis of a Scan system. J Oral Rehabil 1997;24:426-432.
mandibular closure to guide the occlusal adjustments of 13. Garrido-Garcia VC, Cartagena AG, Sequeros OG. Evalua-
the contact sequence, the establishment of true and tion of occlusal contacts in maximum intercuspation using
measurable bilateral simultaneous occlusal contacts the T Scan system. J Oral Rehabil 1997;24:899-903.
now can be an attainable clinical reality. The software 14. Bottger H, Borgstedt T. Computer-supported analysis of
features of real-time recording and the center of force occlusion using T Scan system. ZWR 1989;98:583.
trajectory can isolate .01-second time increments that 15. Combadazou JC, Combelles R, Cadenat H. The value of
show which tooth contacts are prolonging the closure mandibular kinesiography and T-scanning in the temporo-
mandibular joint. Rev Stomatol Chir Maxillofac 1990;91:86.
contact sequence and are interfering with the establish-
ment of true bilateral contact time simultaneity. 16. Kerstein RB. Disclusion time measurement studies: Stability
of disclusion time: A 1 year follow-up study. J Prosthet Dent
Performing the occlusal adjustment that removes these 1994;72:164-168.
premature and prolonged occlusal contacts significantly 17 Kerstein RB. Disclusion time measurement studies; Part 2:
improves the ability of the operator to develop true and A comparison of disclusion time length of 49 chronic myo-
measurable bilateral simultaneous occlusal contacts. fascial pain dysfunction syndrome patients to 40 non-
patients. A population analysis. J Prosthet Dent 1994;72:
473-480.
REFERENCES 18. Maness WL. Computerized occlusal analysis: T Scan II, the
next generation. Compendium (in press).
1. Okeson ]P. Fundamentals of Occlusion and Temporo- 19. Maness WL. Force Movie. A time and force view of occlu-
mandlbular Disorders, ed 1. St Louis: Mosby, 1985:106. sion. Compendium 1989;10:404-408.
2. Dawson PE. Evaluation diagnosis and Treatment of 20. Schuyler CH. Fundamental principles in the correction of
Occlusal Problems, ed 2. St Louis: Mosby, 1989:31-47. occlusal disharmony, natural and artificial. J Am Dent Assoc
1935;22:1193-1202.
3. Carranza FA. Glickman's Clinical Periodontology, ed 5.
Philadelphia: Saunders, 1979:951. 21. Kerstein RB, Wilkerson D. Locating the centric relation
prematurity with the aid of a computerized occlusal analysis
system. Compendium (in press).