CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Clinical protocol for occlusal adjustment: Rationale

and application

Roger A. Solow

To cite this article: Roger A. Solow (2017): Clinical protocol for occlusal adjustment: Rationale and
application, CRANIO®, DOI: 10.1080/08869634.2017.1312199

To link to this article: http://dx.doi.org/10.1080/08869634.2017.1312199

Published online: 11 Apr 2017.

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Download by: [University of Newcastle, Australia] Date: 11 April 2017, At: 10:40
CRANIO®: The Journal of Craniomandibular & Sleep Practice, 2017
http://dx.doi.org/10.1080/08869634.2017.1312199

CASE REPORT

Clinical protocol for occlusal adjustment: Rationale and application

Roger A. Solow DDSa,b
a
Private Practice, Mill Valley, CA, USA; bVisiting Faculty, The Pankey Institute, Key Biscayne, FL, USA

ABSTRACT KEYWORDS
Background: Occlusal adjustment can optimize the result of orthodontics, orthognathic surgery, Occlusion; occlusal
and comprehensive restoration, and resolve adverse forces to the dentition that affect the adjustment; additive occlusal
entire masticatory system. Mounted diagnostic casts and computerized occlusal analysis offer adjustment; computerized
complementary advantages for evaluating occlusal problems. Predictable occlusal adjustment is occlusal analysis; diagnostic
casts; occlusal analysis;
facilitated by precise, measured documentation of occlusal force by computerized occlusal analysis. occlusion; subtractive
Clinical presentation: A conservative, structural correction of a pronounced, chronic occlusal occlusal adjustment
problem by additive and subtractive occlusal adjustment was performed after a previous failed
occlusal adjustment. The patient’s chief concerns were significant anterior teeth fremitus in
maximum intercuspation and “pain in the teeth and a poor bite” after 30+  adjustments over 2.5
years.
Clinical Relevance: Confirmation of specific criteria for a therapeutic occlusion resolved the anterior
teeth fremitus and uneven bite. Traumatic occlusal contact on posterior teeth may elicit protective
mandibular repositioning affecting anterior teeth relationships and should be considered during
comprehensive diagnosis.

Introduction predictability of any occlusally related procedure can be

A goal of optimal dentistry is the long-term stability of
all components of the masticatory system: teeth, perio-
dontium, muscles of mastication, and temporomandib-
ular joints (TMJs). Stability implies that all parts of this
system work in harmony without the destruction of any
component, requiring minimal maintenance over time.
In his seminal text, Dawson [1] attributes the breakdown
of oral structures to microorganisms and physical stress.
Dentists who strive to provide optimal care must create
an occlusion that minimizes adverse force on teeth, which
can affect all components of the system. There is extensive
literature and an anatomic-biomechanical rationale sup-
porting a therapeutic occlusion as integral to the diagno-
sis, treatment planning, and performance of orthodontics,
orthognathic surgery, and restorative dentistry. There is
no evidence demonstrating a benefit by creating or per-
petuating traumatic occlusal contacts.
Excessive occlusal force from contacting teeth affects
multiple tissues with an individual expression of various
combinations of signs and symptoms. The dentist must
know the location, intensity, and effect of these forces
before an intelligent analysis of the advantages and
discussed with the patient.
Precise diagnosis and correction of occlusal problems
are essential for optimal patient care. Failure to diagnose
occlusal problems forces the patient to accept existing
conditions as status quo and compromises the quality
of clinician care. This article reviews the scientific basis
and clinical protocol for occlusal adjustment (OA) and
the effect of posterior tooth occlusal interferences on the
relationship of the anterior teeth. A clinical case of an
occlusal problem subsequent to restoration and unsuc-
cessful OA illustrates the diagnosis, treatment planning,
and technique criteria for predictable occlusal correction.
Tissue-specific effects of occlusal problems
The arc of mandibular closure is the simple, repetitive arc
created when the condyles are fully seated against the most
superior-anterior aspect of the mandibular fossae [2,3].
Force overload occurs on teeth in the arc of closure when
a single tooth contacts prematurely or during mandib-
ular excursions when posterior teeth are torqued later-
ally [4,5]. Mechanoreceptors in the periodontal ligament
(PDL) sense this load and provide exquisite feedback via

CONTACT  Roger A. Solow  rasolowdds@aol.com

© 2017 Informa UK Limited, trading as Taylor & Francis Group
2   R. A. SOLOW
monosynaptic connection of the trigeminal nerve to the
brainstem’s main sensory trigeminal nucleus [6,7]. The
masticatory muscles are programmed to reposition the
jaw away from the traumatic contact [8].
This unconscious response protects the tooth with the
initial contact but may position the jaw with deleterious
contact on other teeth. Undiagnosed posterior teeth occlu-
sal interferences can complicate treatment on seemingly
unrelated anterior teeth. Off-axis loading from posterior
tooth cusp incline contacts also generates stress on the
tooth itself, leading to micro-cracks, abfractions, cusp
fracture, and occlusal wear on teeth or restorations [9–13].
Excessive force on the teeth must be absorbed by the
supporting gingival, connective, and osseous tissues,
resulting in mobility, migration, and loss of attachment.
Crestal bone loss around implants via microfracture is
directly related to nonaxial occlusal force, since there is
no PDL to distribute stress [14]. The majority of fibers in
the PDL are the oblique type and are designed to accept
vertical load from the teeth. Off-axis loading is destructive,
as the PDL does not have an infinite capacity to buffer
occlusal trauma [15]. Similar to inadequate bone thickness
adjacent to implants, paper-thin facial bone in the thin per-
iodontal profile patient cannot be expected to persist with
heavy mechanical stress concentration at the bone crest.
The vector of occlusal stress is especially important
in the presence of bone loss or apical root resorption.
Reduced bone anchorage and a longer lever arm of occlu-
sal force from an increased crown to root ratio creates a
vertical cantilever that amplifies traumatic contacts [16].
Masticatory muscle pain can be directly related to occlu-
sal problems in the natural dentition or after orthodontics,
orthognathic surgery, and restorations. Force overload from
traumatic occlusal contact in the arc of closure or chewing
excursions requires a protective response of mandibular
opening or protrusion to avoid damage to the tooth and
supporting structures. Constant inferior lateral pterygoid
activity is required to maintain this position, which is not
physiologic or comfortable. During closure, elevator mus-
cle (masseter, anterior and middle temporalis, and medial
pterygoid) activity conflicts with the lateral pterygoids,
as these muscle groups are designed to function recipro-
cally [17,18]. This uncoordinated muscle hyperactivity can
produce chronic myalgia, limited opening, compromised
function, and referred pain. The predominance of sensory
innervation in the PDLs compared to the TMJs or mastica-
tory muscles creates the priority of protecting the teeth at the
expense of muscle function or altered TMJ position [19,20].
The condylar position and the occlusal relationship of
teeth are absolutely correlated since they occupy oppo-
site ends of the rigid mandible. Displacement of the
mandibular condyle as teeth slide from the fully seated
condylar position, centric relation (CR), to maximum
intercuspation (MI) is dependent on the horizontal and
vertical components of the slide and the ability of the
TMJ to act as a universal joint that rotates and translates
to accommodate the fit of the teeth. Complete seating of
the mandibular condyles with their medial poles braced
against the mandibular fossae in CR allows the lateral
pterygoid muscles to relax as elevator muscles contract
[21]. A protruded condylar position on the slippery incline
of the articular eminence is not stable and requires bracing
from constant lateral pterygoid muscle hyperactivity.
Force overload from muscle hyperactivity and clench-
ing can displace synovial fluid and affect disc lubrication
and position [22,23]. Intraarticular pressure from clench-
ing has been demonstrated to be consistently higher in
women and may account for the disproportional female
to male ratio in TMJ disorders [24]. Osteoarthritis from
chronic force overload to bone after loss of disc integ-
rity, lubrication, and cushioning may be exacerbated by
increased forces of elevator muscle hyperactivity [25,26].
TMJ remodeling has been documented after occlusal cor-
rection, which may be related to changes in forces to the
joint and condylar position within the joint [27,28].
Occlusal adjustment
Occlusal adjustment (OA) is the precise additive and sub-
tractive reshaping of the chewing surfaces of the teeth to
create a programmed contact that optimally distributes
force on teeth and their supporting structures during
mandibular function. Historically termed selective grind-
ing, it is sometimes thought of as only an invasive proce-
dure. Additive reshaping with composite resin bonding or
conventional restorations can minimize the invasiveness
of the procedure, making it more conservative to avoid
local anesthesia or exposure of dentin [29]. OA can be
done prior to or with comprehensive restoration to allow
work in a stable occlusal environment.
The goals of OA are:
(1)  Stability on mandibular closure with the maxi-
mum number of teeth in simultaneous contact
when the condyles are physiologically seated in
CR.
(2)  Anterior guidance from the most anterior and
periodontally stable teeth smoothly gliding
and separating the posterior teeth during all
mandibular excursions.
(3)  Anterior teeth should not contact more heav-
ily than the posterior teeth or interfere with
the envelope of mandibular function. Patients
should feel a comfortable, even bite with-
out having to protect any sites and be able to
smoothly perform all excursive movements
without displacement of the anterior teeth.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   3
Occlusal adjustment removes posterior teeth occlusal
interferences, typically on cuspal inclines, allowing proper
anterior teeth guidance and immediate canine disclusion.
Canine guidance on periodontally stable teeth protects
the posterior teeth, which are challenged by the highest
intraoral forces [30,31]. Posterior teeth should take only
vertical force aligned with the long axis of the root or
implant. Relief from lateral torque force also minimizes
force effects on the periodontium, elevator muscles, and
TMJs [32–35]. Dentin and thermal hypersensitivity have
been successfully treated by OA [36,37]. Resolution of
gingival clefts following the removal of traumatic contacts
has been documented [38], and OA has been related to a
moderate improvement on periodontal probing depth and
treatment [39,40]. Precise occlusal correction with splint
therapy or definitive OA can successfully treat masticatory
muscle pain and dysfunction [41–45].
Clinical report
Predictable resolution of occlusal problems with OA is
predicated on comprehensive history/examination, appro-
priate imaging, accurate occlusal analysis, patient educa-
tion of problems/solutions, completion of the procedure,
and verification of a therapeutic occlusion. A clinical case
illustrates these steps.
The patient, a 67 year-old male, who had some
improvement with splint therapy, was referred by his
Figure 1. (a-d) Retracted intraoral views. Note the previous wear and reshaping of the occlusal surfaces into dentin. (c, d) Lateral excursive
group function traumatic contacts persist after the previous occlusal adjustment (OA) and correlate to sites of gingival recession.
orthodontist, who was unsure how to provide a definitive
solution. The patient’s chief concern was “pain in his teeth
and an uncomfortable bite.” He described an “unwanted
equilibration” of 30+ adjustments over a 2.5-year period
by his general dentist, initiated by replacement of his max-
illary anterior bridge, but he was still “hitting heavy on his
front teeth.” His medical status was noncontributory for
dental procedures, and clinical examination revealed no
soft tissue pathology, caries, fractures, or defective resto-
rations (Figure 1). A single tooth had increased periodon-
tal probes. Multiple teeth had significant flattening with
dentin exposure from wear or reshaping.
The gold crown on the mandibular left second molar
was perforated. Palpation of the superficial elevator mus-
cles was normal. Range of motion was 48 mm unstrained
opening without deviation and 9  mm in lateral excur-
sions. There was pronounced fremitus on the maxillary
anterior provisional restorations on closure in MI with
1 mm deflection facially. He had bilateral group function
with working interference contacts on all posterior teeth.
TMJ Doppler ultrasound showed moderate crepitus in
excursions, suggesting bilateral lateral pole displacement,
Piper Stage 3B. Cone beam computed tomogram (CBCT)
showed normal TMJ regions with a failed endodontic pro-
cedure on the maxillary right first molar (Figure 2). This
was verified with a current periapical X-ray, and the patient
was referred for endodontic retreatment (Figure 3). The
endodontist confirmed periapical infection with a limited
4   R. A. SOLOW
Figure 2. CBCT reformatted panographic view. The outlines of the
condyles and articular eminences are smooth and regular. There
is no evidence of intracapsular degeneration. The maxillary right
1st molar has a periapical lesion. Image courtesy of Clare Ferrari
DDS, MSD.
Figure 3.  Periapical radiograph showing inadequate cleaning,
shaping, and obturation of the mesiobuccal root with periapical
radiolucency.
field of view CBCT (Figure 4). Detecting periapical infec-
tion is a prerequisite to occlusal correction, as the involved
teeth are not stable and are displaced occlusally.
Diagnostic casts were obtained and mounted on a
semi-adjustable articulator with a facebow and verified
in CR to analyze the occlusion (Figure 5). Centric rela-
tion is accurately and predictably recorded with an ante-
rior acrylic platform that separates the posterior teeth,
preventing them from deflecting jaw closure [46,47].
Bimanual guidance was used to guide repetitive closure,
and the lower incisor contact against the platform was
marked to visualize the consistent arc of closure. When
the platform is placed on the diagnostic casts, the intraoral
mark must contact exactly to confirm the accuracy of
the mounting. These casts identified the arc of closure
interference on the left second molars. Both right and left
canines had an open occlusal relationship with no pos-
sibility of immediate canine guidance or posterior teeth
disclusion. Posterior interferences on lateral excursion
contacts mirrored the clinical view.
Figure 4.  CBCT coronal view. Arrow points to the untreated
mesiobuccal 2 canal. Image courtesy of Natanya Marracino, DMD.
Computerized occlusal analysis was also used to assess
the occlusion (T-Scan® III, Tek-Scan, South Boston, MA,
USA). Similar to magnification with a surgical micro-
scope, T-Scan® technology provides a detailed, objective
method of achieving superior results with OA. During
early closure in MI, the maxillary incisors contacted pre-
maturely and once displaced, the second molars displayed
the heaviest contact, consistent with the diagnostic cast
data (Figure 6). The T-Scan® is an accurate and practical
way to objectively record the location, duration, and inten-
sity of occlusal contact, shown with 2D and 3D graphic
display. Mounted diagnostic casts show in 3D the actual
dimension of arc of closure excursive, which is measured
for precise treatment planning. They also show occlu-
sal plane problems, crossover interferences, and lingual
views of the occlusion; assess contacts in CR as well as
MI; and permit duplication and diagnostic workup to vis-
ualize proposed treatment. Significantly, both methods
allow patients to visualize and immediately understand
their problem instead of only having an abstract verbal
description.
The casts were duplicated and mounted with the same
CR record on a second identical articulator. The trial OA
showed the location and extent of reduction to achieve
multiple posterior contacts, confirm anterior teeth con-
tact, and disclusion of the posterior teeth in excursive
movements (Figure 7). The maxillary canine open contacts
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   5

Figure 5.  (a-g) Diagnostic casts mounted in centric relation on a semi-adjustable articulator. (a) A marked, anterior acrylic platform
verified that the lower incisor arc of closure contact of the mounted casts is identical to the intraoral contact. (d, e) The arc of closure
interference is marked by 20 u Accufilm (Parkell) on the left 2nd molars. (f, g) Tilted view of the canines shows an open contact precluding
immediate canine guidance and posterior tooth disclusion.

were closed by the posterior teeth reduction only on the
right and wax addition on the left. The dentist needs to
know, prior to treatment, if OA will provide a predictable
result by fulfilling all criteria for a therapeutic occlusion or
if orthodontics, orthognathic surgery, or restorations are
needed. The diagnostic and trial OA casts demonstrated
to the patient the structural reasons for his problem and
the appropriate procedures to correct it. Despite repeti-
tive adjustment of his maxillary and mandibular anterior
teeth that created an open occlusal relationship in CR,
the arc of closure interference on the left second molars
and posterior teeth excursive interferences could explain
the mandibular anterior repositioning and pronounced
fremitus.
Time scheduled for thorough diagnosis and discus-
sion of treatment planning was essential, especially in
this case, where OA with bonded palatal composite resin
on the maxillary canines was the recommendation after
the patient had failure of the previous OA. The workup
cast showed that posterior tooth reduction would be less
than 1 mm and could be halved by sharing the reduction
on both arches. Reshaping both maxillary and mandibular
teeth has the advantage of (1) minimal invasion of each
opposing tooth; (2) more natural tooth morphology, as
thick restorations and malposed teeth creating occlusal
plane problems are re-contoured; (3) cusps are sculpted
for proper point contact in the center of the opposing
tooth occlusal table to ensure axial loading; and (4) addi-
tive and subtractive OA is coordinated. The patient was
informed that the thickness of crown material was not
known and perforation could occur, requiring simple
composite resin repair. The alternative of comprehensive
restoration was discussed but not recommended, as the
existing crowns were well sealed, esthetic change was not
6   R. A. SOLOW

Figure 6. (a,b) Preoperative computerized occlusal analysis (T-Scan®, Tekscan) recordings in maximum intercuspation (MI) when closing
on the posterior teeth. (a) Early closure shows only anterior teeth contact, consistent with the pronounced clinical fremitus on the
maxillary anterior teeth. These teeth had to deflect before the posterior teeth could register. (b) Mid-clench closure shows the traumatic
force concentration on the 2nd molars, consistent with the data from the diagnostic casts.

a priority, and the invasion and expense of this approach
was significant. Furthermore, restoration would be more
predictable in a stable, post-OA environment. Splint ther-
apy was previously done by the orthodontist for masseter
and TMJ pain with a positive result, but the patient asked
for a definitive procedure.
Bimanual guidance was used in the CR arc of closure
to confirm that the first contact in the mouth, marked
by 20  u ink ribbon (Accufilm, Parkell, Edgewood, NY,
USA) was identical to the diagnostic casts and to verify
the occlusal analysis. Occlusal adjustment was initiated
with a coarse straight diamond bur (#8647, Brasseler,
Savannah, GA, USA) on the arc of closure interference,
since the patient was avoiding this tooth in closure and
traumatizing the anterior teeth. Occlusal reduction was
repeated, using light pressure that only removed the ink
mark, until there was uniform contact on all posterior
teeth. Both maxillary and mandibular posterior teeth
were sculpted with the mental visualization of the diag-
nostic workup to create cusp form so that the maxillary
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   7
Figure 7.  Diagnostic workup on a duplicate maxillary cast. The
trial OA demonstrated multiple, even, bilateral posterior tooth
contacts to 20  u Accufilm. The open contact of the right side
canines was closed by the minimally invasive occlusal reduction.
The left canines contact was closed by additive OA with wax,
previewing the dimension of bonded composite resin.
palatal and mandibular buccal cusps had point contacts
with the opposing central fossae and marginal ridges. This
places force on the strongest cusps and in the center of
teeth, avoiding traumatic incline contact that creates off-
axis loading. Polishing stones and rubber points (Dura-
Green, Brownie, Shofu, San Marcos, CA, USA) were used
to refine these areas.
Composite resin was then enamel bonded to the max-
illary canines to provide centric stops even with the pos-
terior teeth. Smooth, immediate canine disclusion was
verified with uninterrupted mark lines on the composite
resin addition. The inclination of the canine guidance was
refined so that posterior teeth were discluded without
the patient feeling any discomfort or restriction from an
excessively steep guidance (Figure 8). Minimal reduction
was needed on the palatal surfaces of the maxillary incisor
provisional restorations despite the significant fremitus
prior to OA, confirming the cause of the fremitus was
avoidance of the traumatic posterior tooth interference
[48]. Protrusive excursions were refined to provide even,
uninterrupted mark lines on the central incisors, indicat-
ing a shared distribution of force.
The CR contacts on the maxillary incisors were fur-
ther lightened to allow for repositioning from PDL nor-
malization after removal of the occlusal trauma. T-Scan®
recordings documented even, symmetrical posterior
teeth contact with lighter anterior teeth contact. The
deflective anterior tooth contacts in initial closure and
their causative second molar premature contacts were
resolved (Figure 9). Smooth, immediate, bilateral canine
guidance discluding the posterior teeth within 0.4 s was
established and verified in medial to lateral and lateral to
medial directions and then video-recorded (Figure 10).
The patient confirmed an even bite on the posterior teeth
with no fremitus on the anterior teeth. The mandibular left
second molar gold restoration perforation was repaired
with composite resin. When asked to compare the before
and after bite, the patient commented, “you have done in
one appointment what my dentist couldn’t do in 2.5 years.”
T-Scan® driven occlusal refinement on postoperative visits
confirmed consistent ink ribbon markings in closure and
all excursive movements.
Discussion
Diagnosis of occlusal relationships is typically done with
visual inspection of tooth relationships and ink ribbon
marks. Although these methods give a gross estimation of
the patient’s occlusion, neither of these methods is accept-
able for occlusal analysis or refinement during occlusal
correction procedures. Asking the patient to close on their
back teeth to identify an occlusal interference will not
provide a correct bite relationship with the condyles fully
seated in the mandibular fossae. Patients avoid the CR
interference in the arc of closure, as periodontal mech-
anoreceptors immediately program positioning muscles
to avoid this trauma [49]. Studies consistently show the
condyle displaces from CR as teeth close in MI, where
more teeth contact to distribute the closing force with
less pressure on each tooth [50–52]. In the healthy TMJ,
the vector of elevator muscle contraction fully seats the
condyle and TMJ disc against the superior-anterior aspect
of the mandibular fossa, unless interfering teeth trigger
the lateral pterygoid muscle to reposition the jaw and dis-
place the condyle [53]. Failure to assess tooth relationships
with the condyle properly seated to the full extent of the
mandibular border movement means the dentist cannot
accurately treatment plan or intelligently discuss prob-
lems/solutions caused by the actual CR-MI discrepancy.
The anterior acrylic platform separates the posterior
teeth, preventing any tooth from misguiding the man-
dible and facilitates an accurate CR record by decreasing
elevator muscle activity, which relaxes the jaw [54]. The
stone casts do not allow any tooth intrusion and identify
interferences accurately, whereas clinical mobility of teeth
allows movement that may cause several teeth to mark,
even if the mandible is guided into the arc of closure. The
vertical and horizontal dimensions of the arc of closure
interference can be measured at the incisors as the differ-
ence in overlap and overjet compared to MI. The anterior
space caused by the CR interference can also be recorded
with wax on the model and measured with calipers.
Trial OA for a large vertical component to the arc
of closure interference is important because a greater
degree of reduction may be required to close the CR to
8   R. A. SOLOW

Figure 8.  (a-e) Full mouth OA with the occlusion marked by 20 u Accufilm. (a,b) As previewed on the diagnostic workup, bilateral,
multiple, even posterior tooth contacts were achieved on cusp tips and marginal ridges without any incline contact. This resulted in
vertical forces on the posterior teeth with no adverse lateral torque. (c) Line contacts on the maxillary central incisors and canines
indicate immediate anterior guidance on the roots most capable of tolerating that stress. (d, e) Posterior tooth disclusion protects the
posterior teeth and periodontium from traumatic lateral torque.

MI discrepancy. Additive OA with bonded composite
resin, bonded porcelain, or conventional restorations on
anterior teeth can decrease occlusal reduction of poste-
rior teeth. Typically, there is an approximate 2:1 ratio of
reduction at the molars to space closure at the incisors. A 1
mm restorative augmentation of maxillary palatal incisor
or canine contours would avoid a 0.5 mm molar reduc-
tion. The occlusal matrix technique can preview the exact
amount of reduction generated by the trial OA [55,56]. A
rigid acrylic resin wafer that records the occlusal third of
the diagnostic cast is filled with bite registration material
and placed over the trial OA cast.
After it is set, the bite registration material is removed
and measured by calipers so the dentist knows at each
tooth site the degree of invasion that created the planned
occlusion. Trial OA for a large horizontal component to
the arc of closure interference is important because an
anterior open occlusal relationship may result as this inter-
ference is corrected.
Lack of anterior teeth contact and guidance in man-
dibular excursions places stress on posterior teeth where
the intraoral forces are highest in the mouth. This is the
opposite occlusal scheme from protective canine guid-
ance. Masticatory muscle hyperactivity results from pro-
longed posterior teeth contact, contributing to myalgia,
as seen in this patient’s history [57,58].
Diagnostic casts and workup casts are especially useful
when there is a large discrepancy (>1 mm) between CR
and MI, when patient education is a priority, and when
the dentist is learning OA procedures. Since OA is often
performed in conjunction with restorations or interdis-
ciplinary procedures, these casts show the patient the
best way to integrate additive and subtractive occlusal
correction.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   9

Figure 9. Postoperative computerized occlusal analysis (T-Scan®) in CR closure. The patient can now close on his posterior teeth without
having to deflect the anteriors out of the way. Note the correction of the pronounced initial 2nd molar arc of closure interferences. There
is an even and symmetrical contact pattern on the posterior teeth with lighter contact of the anterior teeth.

Figure 10. Left lateral mandibular excursion. The T-Scan® registers sole occlusal force on the maxillary left canine where composite resin
was sculpted to provide a definite CR contact and posterior teeth disclusion within 0.4 s.

Ink-ribbon marking shows if there is contact on teeth
by the presence or absence of a mark. Contrary to conven-
tional wisdom, there is no correlation with mark inten-
sity and occlusal contact force, and dentists misinterpret
occlusal contact force by relying on ink marks [59–62].
This precludes accuracy in occlusal analysis or occlusal
correction procedures. The heaviest marks occur from
light contact where there is room for the ribbon to leave
a mark, not from the highest force [63]. Since the aver-
age tooth displaces 100–200 u due to the PDL resiliency,
multiple teeth may seem to mark even or equally, when
the reality is the premature contact tooth was intruded and
then other teeth marked. Simply having the patient close
on ink ribbon and correcting the offending marks may
cause unnecessary loss of tooth or restoration structure
unless a proper occlusal analysis is done.
Computerized occlusal analysis with the T-Scan® accu-
rately interprets ink ribbon marks, showing the actual tim-
ing and relative force of contact with 2-D and 3-D graphic
displays [64]. This objective documentation guides the
10   R. A. SOLOW
dentist to adjust the correct areas without misinterpreting
ink marks. T-Scan® technology also precludes subjective
patient input misguiding the OA procedure. Patients cannot
accurately assess occlusal interferences by location or inten-
sity. In this case, the patient was continually surprised by
the location of the remaining occlusal misfit on the graphic
display yet was adamant about where he felt the problem.
Clearly, this was a problematic factor in his previous pro-
cedure. Since the dentist is responsible for the quality of
the OA, the T-Scan® technology protects against the patient
controlling the procedure and then criticizing the result.
Postoperative appointments refine changes from
repositioning of teeth after heavy forces that intruded,
or displaced teeth were removed. Teeth with widened
PDLs from occlusal trauma will reposition as the PDL
narrows and the tooth reaches equilibrium within the
alveolus under physiologic occlusal load. A minimum of
two postoperative visits should be scheduled with the OA.
The objective goals of OA, listed above, were achieved and
documented by the T-Scan® records so the patient could
appreciate that the endpoint of treatment was justified.
Final vs. initial T-Scans® and ink marks were shared with
the patient to show the predicted workup cast occlusion
was achieved and the arc of closure interference and
trauma to the anterior teeth were resolved.
In this case, the occlusion was adjusted on posterior
teeth first to have multiple, even posterior teeth contacts,
and then the anterior teeth were augmented to create CR
contacts and optimal anterior guidance. The sequence
of OA can be customized for each patient’s problem set.
Becker [65] corrected CR interferences followed by excur-
sive interferences and maintained vertical dimension by
preserving CR contacts. Solnit [66] eliminated protru-
sive interferences first, then lateral interferences so that
anterior guidance could occur on the central incisors and
canines. Kerstein [58] eliminated excursive contacts to
create immediate canine guidance with posterior tooth
disclusion. No attempt was made to guide the condyle
to seat in CR. Since most interferences to CR occur on
inclines that are also excursive interferences, this approach
should also correct CR interferences.
Occlusal interferences to the arc closure can also be
detected with the T-Scan® during CR bimanual guidance
by observing initial, repetitive low force contact [67]. This
is an essential step in occlusal refinement, where both the
CR position, with the condyles medially braced and the
patient supine as well as in the un-braced position, with
the patient upright and closing on their own, are checked.
For initial occlusal analysis of arc of closure interferences,
this author prefers the anterior acrylic platform technique,
as the incisor contact is marked and visualized, confirming
the patient is repetitively closing on the true arc of closure.
Additionally, there is no contact of the posterior teeth or
instrument in the mouth, an assistant is not needed, and
the platform can be placed on the final models, verifying
the accuracy of the CR mounting.
Whether via diagnostic casts or observation during
bimanual guidance, clinicians need to assess whether a
large horizontal component of the arc of closure interfer-
ence would affect anterior teeth relationships after occlusal
adjustment. The concern, as in this case, is that finding
the initial contact on the anterior teeth with either ink
marking or T-Scan®, this endpoint of the CR to MI slide
would be adjusted instead of the CR interference itself.
Comprehensive occlusal analysis was essential to under-
standing that avoidance of the posterior tooth interference
was the cause for the anterior teeth trauma and fremitus.
Digital occlusal analysis documents the true intensity
and timing of occlusal force, giving the clinician the abil-
ity to accurately diagnose and treat occlusal problems as
never before. OA that removed lateral excursion posterior
teeth interferences so that canine guidance separated the
posterior teeth within 0.4 s. was found to create predict-
able and durable relief of signs and symptoms of myofas-
cial pain [43–45,68,69]. Restorations placed in a mixed
natural dentition-implant environment can have occlusal
forces properly refined to avoid implant overload [70,71].
Post-orthodontic OA can provide patients with a more
stable occlusion by removing deflective contacts that affect
relapse [72]. Research that uses this technology to measure
timing, intensity, and duration of force on teeth has shown
the true relationship of the occlusion to masticatory mus-
cle problems. Research based on the unmeasured visual or
ink ribbon assessment of the occlusion has been obviated
by this technology [73].
Conclusion
Diagnosis and correction of occlusal problems is integral
to providing optimal dental care. Current technology
allows clinicians and researchers to objectively analyze
and measure the location, intensity and duration of
adverse occlusal forces. Diagnostic models can also be
used to measure occlusal relationships in 3-D. Both offer
the clinician and patient the ability to visualize true occlu-
sal relationships not seen with simple visual inspection
or ink-ribbon marking. Predictable occlusal correction
is predicated on comprehensive diagnosis, and comput-
erized occlusal analysis is essential for documenting that
a therapeutic occlusion has been achieved.
Contributor
Dr. Solow is the sole author of the manuscript.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   11
Disclosure statement
No potential conflict of interest was reported by the author.
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