A Review of Digital Occlusal Analysis Technologies by Dr. Robert B. Kerstein

Clinical applications and a representative T-Scan case example

by Dr. Robert B. Kerstein

Over the past decade, a number of new digital occlusion technologies have been developed for dental clinicians. The field of measured digital occlusion is expanding through new tools that, in differing ways, “measure” the occlusion, representing an advance in patient occlusal care. Despite their widespread clinical use, articulating paper marks and shimstock hold have been shown to be inaccurate,^1-3 are subjectively employed, and clinicians struggle to predictably adjust the true problem occlusal contacts.^4-7 The aim of this article is to describe several modern occlusal diagnostic technologies that are advancing the outcome precision offered to patients undergoing occlusal adjustments.

These digital occlusion tools fall into three categories:

• Diagnostic occlusal spatial interrelationship technologies that digitize restorative fabrication

• Absolute force measurement technology

• Sensor-based occlusal contact force, time, and pressure mapping technologies that can guide measured occlusal adjustments

Because the available technologies differ in their published clinical protocols and documentation, the case example presented here uses T-Scan data to illustrate how digital occlusal analysis may be incorporated into treatment.


Digital restorative technologies

• IOS scanners (many companies): Scanners optically capture occlusal morphology with all teeth out of contact, then algorithmically intercuspate the patient’s virtual arches.

Scanners capture the dental anatomy without recording occlusal force levels or contact timing, and use color-coded scales to describe occlusal contact approximation. The software generates an “occlusogram” that can be used to design crown contours with variable “penetration depths” of virtually designed opposing occlusal contacts (Fig. 1).

• MODJAW: Virtual articulation of IOS-scanned virtual casts that move in space the way the patient’s mandible functionally moves. A patient’s functional motions are recorded and played back using their virtual casts to recreate the patient’s motion patterns.

The traditional procedures being modernized by IOS and MODJAW are:

• Material and tray-based intraoral impressions

• Mechanical articulator and stone cast mounting procedures

• Fully adjustable articulators with condylar tracing elements

IOS scanners and MODJAW are diagnostic in nature, offering clinicians spatial reproduction accuracy improvements and, with MODJAW, jaw motion reproduction accuracy improvements to better diagnose a patient’s macro-occlusal opposing tooth-to-tooth relationships. Both technologies minimize laboratory steps, stone setting times, and mounting stone setting contraction errors by virtually articulating .stl file casts, with and without cast motion. Articulators are needed only for the final steps of restorative fabrication, because virtual cast articulation allows for a detailed visual occlusal analysis of the macro-occlusion and for the digital design and CAD/CAM fabrication of restorations.

The macro-occlusion comprises the interocclusal arch relationships and the anatomical tooth-to-tooth orientations. Importantly, the quality of the macro-occlusal alignment does not guarantee that individual occlusal contact forces or timing will be physiologic, which is why insertion occlusal adjustments are needed at the end of the digital workflow.

Because all teeth are out of contact when IOS scanning is performed, and no sensor is placed between occluding teeth, scanners do not measure occlusal contact forces. A recent IOS study reported that scanner occlusograms could not determine interocclusal contact forces in a clinically useful way, such that IOS occlusogram data cannot be used to adjust the occlusion (Fig. 2).⁸

Fig. 2: Occlusogram color-coded distance data estimates how closely teeth meet, but not the pressure they generate during function.

Absolute bite force measurement

• Innobyte: Kube Innovations, Canada; five years since inception. Innobyte reports a patient’s total absolute bite force, replacing mechanical strain gauges for intraoral absolute bite force measurements (Fig. 3).

Fig. 3: By applying bite pressure onto a compressible, fluid-encased silicone pad, Innobyte converts applied bite force into a digital readout in newtons (one newton = 0.225 pounds of force).

Innobyte’s main use is to match patient bite force levels (strength) to restorative materials that can withstand that patient’s repeated intercuspations and excursions. Innobyte can also determine whether prosthodontic or occlusal treatment resulted in increased or decreased total bite force.⁹ However, Innobyte numerical force values do not describe how to improve that intervention’s absolute bite force strength. Innobyte does not measure a single tooth’s bite force or a quadrant of bite force, and, like IOS scanners and MODJAW, its absolute force values cannot guide occlusal adjustments.


Sensor-based occlusal analysis
Two sensor-based relative occlusal force digital analysis systems can diagnose and treat the micro-occlusion contact forces. The micro-occlusion comprises the individual contact force levels, their timing synchronicity, and how measurably balanced the pressure mapping is between opposing teeth and arches. Printed electronic circuit sensors placed between the arches capture changing closure or excursive occlusal forces from within intercuspating and excursing teeth.

• T-Scan 10 Novus: Tekscan, Inc., USA. The T-Scan system has undergone 42 years of sensor and system evolution and many product iterations since being developed in 1984.^10,11 The high-definition sensor measures 256 relative occlusal forces captured in 0.003 seconds per frame. T-Scan has validated patient treatment protocols using force, pressure, and timing metrics intended to address common occlusal problems (Figs. 4 and 5).^12-16

• OccluSense: Bausch GmbH, Germany; six years since inception. OccluSense records 256 relative occlusal forces at 0.056 seconds per frame. Its sensor is coated with red ink to mark teeth like articulating paper and is set in a single-use cardboard frame (Fig. 6).^17,18

Fig. 4: The T-Scan 10 Novus handpiece with an HD sensor and the sensor centering support (left). Placing the Novus handpiece intraorally to dynamically record changing contact forces (right). The T-Scan desktop in .stl mode, ready for playback and occlusal analysis (bottom).

Fig. 5: The thin, flexible T-Scan sensor adapts to the occlusal surfaces as the patient intercuspates.

Sensor-based digital occlusal analysis addresses the documented inaccuracies of traditional occlusal indicators, which have no known force measurement capabilities.^1-7,19-21 T-Scan and OccluSense are used in place of articulating paper, foil, silk ribbon, occlusal wax, and shimstock, all of which attempt to illustrate differing occlusal contact forces by their appearance. However, multiple studies found that dentists chose the wrong high- and low-force contacts approximately 90% of the time^4-7 when subjectively interpreting ink markings, making articulating paper an unreliable force guide when adjusting the micro-occlusion.¹⁹

Fig. 6: The OccluSense recording handle and red-ink-coated sensor.

T-Scan and OccluSense are the two sensor-based systems that record and analyze the micro-occlusion. The clinical case below illustrates how T-Scan force and timing data guide occlusal adjustments, including on implant restorations.^12-16

T-Scan sensors are printed electronic circuits. They are not coated with ink, so T-Scan is used together with thin articulating paper (23 microns). This T-Scan + articulating paper method¹⁵ locates problem contact forces on teeth or implants, which are then targeted for precise adjustment.^12-15,24


Clinical case: Implant occlusal adjustment
The T-Scan + articulating paper method involves mapping elevated or time-premature contacts to the articulating paper marks, then adjusting only the ink marks that T-Scan flagged as force- or time-wise problematic.

Fig. 7a

Fig. 7b

In a representative implant case, courtesy of Dr. Riaz Yar (Fig. 7a), the T-Scan arch was modified to match the patient’s dentition, simplifying the location of high-force contacts. Low-force contacts (dark blue or blue) can be reshaped for contact-area improvements, while moderate- and high-force contacts (green, yellow, orange, red, or pink) are adjusted by treating only the corresponding ink marks.

Initially, 64.1% of the contact force was concentrated on the left side (Fig. 7b). After the moderate-to-high-force contacts were adjusted, a new MIP (maximum intercuspation) recording was made to view the resulting changes, and the process was repeated until T-Scan reported widespread low-force contacts and a balanced, centered COF (center of force) trajectory. The corrected profile finished within the COF balance target at 50.8% left and 49.2% right (Fig. 7c).

Fig. 7c: The corrected force profile with low-to-moderate forces throughout. The COF trajectory travels fairly straight anteroposteriorly to finish within the COF balance target. Corrected force distribution: 50.8% left, 49.2% right.

Training considerations
Sensor-based digital occlusion technologies do not work simply by being placed intraorally for a patient to bite down on. To be clinically effective, clinicians must learn to:

• Record useful digital occlusal data from patients. The clinician must manage the sensor and recording handle while communicating to the patient how to repeatedly intercuspate and excurse with the sensor between their teeth.

• Apply the force and timing software tools to make an accurate occlusal diagnosis.

• Transfer problematic force and timing data to the occlusal surfaces to perform targeted, computer-guided corrective adjustments.

As with any digital occlusal analysis technology, clinicians should obtain appropriate training to ensure accurate data collection, interpretation, and clinical application. Training requirements and educational resources vary by system.

Digital occlusal technologies continue to evolve, providing clinicians with increasingly objective methods for evaluating occlusal relationships, force distribution, and bite function. While individual systems measure different aspects of occlusion and serve different clinical purposes, these technologies collectively represent a shift toward more data-driven occlusal assessment.

References
1. Carey, J.P., Craig, M., Kerstein, R.B., & Radke, J. (2007). Determining a relationship between applied occlusal load and articulating paper mark area, The Open Dentistry Journal. 1, 1-7.
2. Qadeer, S., Kerstein, R.B., Yung Kim, R.J., Huh, J.B., & Shin, S.W. (2012). Relationship between articulation paper mark size and percentage of force measured with computerized occlusal analysis. Journal of Advanced Prosthodontics, 4, 1-6.
3. Saad, M.N., Weiner, G., Ehrenberg, D., & Weiner, S. (2008). Effect of load and indicator type upon occlusal contact markings. Journal of Biomedical Materials Research, Part B, Applied Biomaterials, 85(1), 18-22.
4. Basson, E., Kerstein, R.B. & Radke, J. (2020). Ability to correctly select high force occlusal contacts from articulating paper markings. Advanced Technologies and Techniques, 2(1), 101-10.
5. Kerstein, R.B., & Radke, J. (2013). Clinician accuracy when subjectively interpreting articulating paper markings. The Journal of Craniomandibular & Sleep Practice, 32(1), 13-23.
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14. Thumati. P., Thumati, R.P., Poovani, S., Sattur, A., Srinivas, S., Kerstein, R.B., & Radke, J.A. (2021). Multi-Center Disclusion Time Reduction (DTR) Randomized Controlled Occlusal Adjustment Study Using Occlusal Force and Timing Sensors Synchronized with Muscle Physiology Sensors. Sensors, 21, 23, 7804 https://doi.org/10.3390/s21237804
15. Lerner, H., Mangano, C., Luongo, G., Mangano, A., Luongo, F., Van Stralen, K., Kerstein, R.B., & Radke, J. (2024). Implant Complications After Installation with Traditional vs. Digital Occlusal Indicators. Advanced Dental Technologies and Techniques. Published online February 13, 1-15.
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Dr. Robert B. Kerstein is a nationally recognized prosthodontist, educator, and researcher with more than 40 years of experience studying occlusion, temporomandibular disorders, and restorative dentistry. After earning his DMD and prosthodontic certificate from Tufts University School of Dental Medicine, he served as a clinical professor for more than a decade. He has published extensively in peer-reviewed dental journals and edited nine research volumes on occlusion and computerized bite analysis. His work has focused on advancing objective approaches to occlusal evaluation and improving the understanding of how bite function influences restorative outcomes, patient comfort, and long-term oral health.