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T Scan – An aid in achieving stable occlusion during finishing stages of

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DOI: 10.1007/s12548-016-0144-z

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J. Stomat. Occ. Med.
DOI 10.1007/s12548-016-0144-z
T Scan – An aid in achieving stable occlusion during
finishing stages of orthodontic treatment
Vidushi Seth · Anand K. Patil · Harshavardhan Kidiyoor · Konark Patil
Received: 20 November 2015 / Accepted: 24 February 2016
© Springer-Verlag Wien 2016
Abstract
Background  Superficial clinical examination of occlu-
sion and just assessing the morphologic relationship of
teeth at the finishing stages of orthodontic treatment may
be insufficient. A case with a clinically satisfying occlu-
sion may be functionally unbalanced. Evaluating occlu-
sion both statically and functionally for uniform distri-
bution of occlusal load is essential for optimum results
and therefore, it is imperative to evaluate the occlusal
contacts in the vertical plane.
Aims  The aim of the study was to quantitatively assess
the occlusion at the pre finishing stage of orthodontic
treatment using T Scan in order to identify the various
occlusal variabilities and compare it to the occlusion
achieved after 1 month of completion of orthodontic
treatment.
Methods  Quantitative occlusal analysis using T Scan
was performed on 16 adult patients at the start of finish-
ing stage (T1) followed by a detailed finishing and set-
tling phase of 2 months. Another scan was taken 1 month
after debonding (T2).
Results  Using Wilcoxon matched pair test, statistically
significant changes were seen in mandibular position
and occlusal contacts at T2 as compared to T1. Relatively
equal distribution of forces on both sides of the arch
was also achieved after a detailed finishing and settling
phase.
V. Seth () · A. K. Patil · H. Kidiyoor
Department of Orthodontics and Dentofacial Orthopedics,
SDM College of Dental Sciences and Hospital,
580009 Dharwad, Karnataka, India
e-mail: sethvidushi@gmail.com
K. Patil
Department of Prosthodontics,
SDM College of Dental Sciences and Hospital,
Dharwad, Karnataka, India
T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment   1
original article
Conclusions  Evaluation of the number and distribu-
tion of occlusal contacts at the end of active orthodontic
treatment has not been a routine procedure in orthodon-
tic clinics. 2 months of extensive finishing and detail-
ing phase resulted in marked improvement in all three
parameters and favorable changes in occlusion. Hence,
evaluation of occlusion using T Scan is an innovative and
objective method, emphasizing that proper finishing is
mandatory for obtaining functionally stable occlusion.
Keywords  Finishing  · Occlusion  · Functional Occlu-
sion · Stable Occlusion · T Scan
Introduction
The objective of orthodontic treatment is to achieve func-
tional occlusion, good esthetics, and stability at the end
of active treatment [1].
The works of Angle and Andrews have established the
morphologic relationship of dental arches [2, 3], but to
date the features of ideal functional occlusion have not
been conclusively established. When dealing with com-
plex malocclusion with fixed appliances, orthodontists
modify dental contacts to achieve a new position of
occlusal equilibrium and take responsibility for its func-
tional integration. It has been universally understood
and agreed upon that irrespective of the therapeutic phi-
losophy (Ricketts, Roth, Tweed Merrifield, MBT) special
attention should be given to the quality of the final occlu-
sion and the restoration of masticatory and postural
function. In order to obtain functional occlusion, stable
centric stops should be present on all teeth in maximum
intercuspation [1].
An orthodontic evaluation of occlusion should there-
fore include evaluation of dynamic occlusion along
with the relationship of the jaw in which the patient
occludes. Traditionally, static occlusion has been evalu-
 original article
ated by direct visual inspection of stone casts, listening to
patients’ “feel” feedback, or by evaluating the articulating
paper marks. These methods are neither accurate (inevi-
tably produces false-positive results) nor conclusive.
More recently, occlusal contacts are being evaluated by
using Blu-Mousse (low-viscosity impression material) or
the Pre-Scale Occlusal system (pressure-sensitive wafers
used for occlusal force assessment). These imprints have
to be further digitally scanned and analyzed.
For dynamic evaluation of occlusion, generally the
cumbersome and time-consuming technique of mounting
models on semi-adjustable articulators (SAM-II etc.) has to
be employed, which is not routinely possible for each case
except for complicated cases of asymmetry or when a cus-
tomized positioner type retainer is to be made [3].
T-Scan (Tekscan Inc., Boston, Mass.) is an easy to use,
digital occlusal analysis tool that helps to easily evaluate
and register occlusal parameters such as occlusal con-
tacts and forces both statically and dynamically in vary-
ing clinical situations.
Studies have been conducted with T-Scan to evalu-
ate occlusal contacts and forces after orthodontic treat-
ment and also to evaluate occlusal parameters before
and after treatment. No study to our knowledge has
been conducted to evaluate the occlusal parameters in
the pre-finishing stage of orthodontic treatment before
appliance removal [3].
Aim of the study
It has been observed that orthodontic treatment without
a detailed finishing and settling phase leads to frontal
and lateral open bite, even if the arches were correctly
aligned [4]. Assessing the occlusion in the finishing
stages of the orthodontic treatment by a superficial clini-
cal inspection following Angle’s classification may lead
to errors. To objectively assess the occlusion, it is impera-
tive to evaluate the occlusal contacts in a vertical plane,
in order to identify the occlusal variabilities at the pre-
finishing stage itself. T-Scan offers a chairside, real-time
visualization of a patient’s occlusion and helps to identify
the occlusal variabilities in the vertical plane.
Therefore, T-Scan was used in this study to test a
newer, easy-to-use tool in an orthodontic set-up and to
determine its efficacy in identifying occlusal problems at
the pre-finishing stage of orthodontic treatment.
The aim of this study was to quantitatively assess
the occlusion at the beginning of the finishing stage of
treatment using T-Scan in order to identify the occlusal
variabilities present and compare it with the occlusion
achieved after 1 month of active orthodontic treatment.
Materials and methods
This clinical study was conducted at the SDM College of
Dental Sciences and Hospital, Dharwad, on a total of 16
patients undergoing orthodontic treatment.
2   T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment
All patients were being treated with pre-adjusted edge-
wise appliances with an MBT prescription. The patients
considered in the study were in the finishing stages of
treatment with complete space closure achieved.
T-Scan (Tekscan Inc.) is a computerized occlusal ana-
lyzer. It provides a real-time digitized analysis of occlu-
sion in both static and dynamic modes and records the
distribution of occlusal forces and occlusal contacts rep-
resenting it in a graphical form. It uses a sensor unit that
records occlusal contacts on a thin two-layered flexible
Mylar film (60–85 μm) inserted into an autoclavable sen-
sor handle that is plugged into a USB port and relayed to
the computer.
During data collection, the subjects were seated in the
same position. Each patient was instructed and taught
how to move their mandible from the rest position to
the maximum intercuspal position (MIP) using a com-
fortable amount of biting pressure. The slim horseshoe-
shaped recording sensor was then placed in between
the dental arches and when the subject intercuspated
the data were processed and represented graphically in
two or three dimensions [5–7] on the computer screen
(Fig. 1).
Three consecutive bites were registered for each sub-
ject while the sensitivity of the sensor remained the same
for every recording. The T-Scan system recorded the
changes in occlusal contact at a time interval of 0.01  s
producing dynamically changing data.
Using the T-Scan system, three parameters were eval-
uated in all subjects (Fig. 2):
1. Distribution of occlusal contacts on both sides of the
arch: Qualitative assessment.
2. Occlusal force levels on the right and left side: This
represents occlusal forces exerted on the teeth on that
side of the arch. It gives us a relative (percentage) dis-
tribution of occlusal forces on both sides of the dental
arch.
3. Mandibular position/center of force: This represents
the position of the mandible upon closing i.e – devi-
ated or centric. It is considered centric if the diamond-
shaped icon (red coloured) is placed in the white or
Fig. 1  Positioning of the T-Scan sensor in the patient’s mouth

Fig. 2  Three parameters
evaluated with T-Scan
Fig. 3  T-Scan of patient 1 at T1
gray area and deviated if it lies outside it. It denotes the
balance of forces between the point of the first and last
tooth contact.
All patients were analyzed quantitatively by taking a
scan at two intervals: T1and T2.
T1 was at the beginning of the finishing and detail-
ing stage. At this stage, complete space closure had been
achieved and clinically the occlusion appeared to be
satisfactory. These three parameters were recorded and
analyzed at T1 for all 16 patients.
Depending on the occlusal variabilities and the prob-
lems identified for each patient, attempts were made to
specifically correct them during 2  months of extensive
finishing and detailing. Identification of interferences at
T1 in the vertical plane using T-Scan helped in tuning the
orthodontic tooth movement as per the requirements of
each case during the finishing phase.
The following was carried out during the 2 months of
the finishing and settling phase depending on the prob-
lem areas identified:
●● Settling elastics in various configurations were given
to patients.
●● Occlusal adjustments were performed that included
posterior torque corrections.
●● V bends for root parallelism were used.
T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment   3
original article
Patients presenting with unequal force distribution on
either side of the arch were given settling elastics of dif-
ferent gauges.
●● Side with lesser force: a heavier gauge elastic was pre-
scribed.
●● Side with higher force: a lighter gauge elastic was given
to balance the force levels.
In order to improve the posterior settling of teeth and in
patients with sparse occlusal contacts all along the dental
arch, the finishing wire was cut distal to the anterior teeth
in order to allow the posterior teeth to settle better with
elastics.
As seen with T-Scan at T1, patients with heavy contact
in the posterior region of the arch were given finishing
bends in the wire to incorporate the buccal root torque
and prevent hanging palatal cusps. Figure 3, 4 shows the
T Scans of 2 patients recorded at T1.
At the end of 2  months of extensive finishing and
detailing, debonding was performed and 1  month later
another T-Scan was carried out: T2 measurements were
recorded for each patient and compared with T1 (Fig. 5,
6 shows the T Scan of the same two patients evaluated
at T2. The changes in all the 3 parameters achieved by
detailed finishing and settling can be observed when
compared to the T Scans recorded at T1.).
 original article
Fig. 4  T-Scan of patient 2 at T1
Fig. 5  T-Scan of patient 1 at T2
Fig. 6  T-Scan of patient 2 at T2
Results
The data of all 16 patients were statistically evaluated for
the three parameters by comparing the intervals T1 and
T2.
Comparison of occlusal contacts at T1and T2 by Wil-
coxon matched pair testing showed a 31 % increase in
the patients having equal contacts at T2, which is statis-
tically significant (p = 0.0117;statistical significance set at
p< 0.05) as shown in Table 1.
The distribution of occlusal force levels shows a sig-
nificant change in the force levels on the right and left
side (p = 0.028 and p = 0.023, respectively) as depicted in
Tables 2, 3, and 4.
A comparison of the mandibular position (Table  5)
showed a significant change at T2 (p = 0.0277). In all,
4   T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment
87.5 % of the readings at T2 showed a centric position of
the mandible as compared with 12.5 % that had a devi-
ated mandibular position after the active phase of orth-
odontic treatment.
Discussion
This short clinical study was carried out on a sample of
16 patients. A young homogeneous adult population was
chosen so that the subjects had sound dentition and nor-
mal occlusion. In order to minimize experimental vari-
ables, a single operator took all the scans, the sensitivity
of the sensor was calibrated, and the upper pressure leg-
end field was set to 255 and the lower pressure legend
field to 0.
 original article

Table 1  Comparison of occlusal contacts at T1 and T2 by Table 4  Comparison of T1 and T2 force levels in left side
Wilcoxon matched pairs testing by paired t test
Occlusal contacts T1 % T2 % Treatment Mean SD Mean SD Paired t p
Equal 1 6.25 5 31.25 diff. diff.
Right side 9 56.25 9 56.25 T1 53.83 13.84 5.89 9.36 2.5171 0.0237*
Left side 6 37.50 2 12.50 T2 47.94 6.84
Total 16 100.00 16 100.00 *p < 0.05
Wilcoxon matched pairs test, Z = 2.5205, 0.0117*
*p < 0.05 Table 5  Comparison of mandibular position at T1 and T2 by
Wilcoxon matched pairs testing
Mandibular position T1 % T2 %
Table 2  Comparison of right and left sides with change in
force levels from T2 to T1 Center 8 50.00 14 87.50

Side Mean SD t p Deviated 8 50.00 2 12.50

Right side 5.75 9.47 3.4962 0.0015* Total 16 100.00 16 100.00

Left side − 5.89 9.36 Wilcoxon matched pairs test, Z = 2.2013, 0.0277*

*p < 0.05 *p < 0.05

Table 3  Comparison of T1 and T2 force levels in right side
by paired t test
Treatment Mean SD Mean SD Paired t
diff. diff.
T1 46.31 13.92 − 5.75 9.47 − 2.4279
T2 52.06 6.84
*p < 0.05
To date, evaluation of the number and distribution of
occlusal contacts at the end of active orthodontic treat-
ment has not been a routine procedure in orthodontic
clinics. It has been established that the examination of
the inter-arch occlusal relationship intra-orally or on
a study cast in the space closure stage does not always
accurately reveal the number and the location of occlusal
contacts [4].
Traditionally used methods of occlusal contact evalu-
ation such as articulating paper have been shown to give
false-positive results and the sensitivity of the paper is
often affected because of saliva impregnation, as was
shown in the study by Saracoglu et al. [8]. Further, artic-
ulating paper does not give any information about the
force with which each tooth contacts in the arch. Saraco-
glu and colleagues showed that T-Scan sensors are totally
unaffected by moisture, and therefore the precision
and recording sensitivity of the sensors are maintained.
Hence, T-Scan was used as it provides a reliable and
reproducible objective recording of the various occlusal
functions and even the relative force distribution.
A number of studies have been reported on the occlu-
sal contacts observed after treatment. In their study of 138
subjects, Fleming and coworkers [9] measured the Objec-
tive Grading System scores of posttreatment Angle Class
I non-extraction patients and concluded that occlusal
contact was the most important component contributing
to the overall score. Wang and Bai [10] conducted studies
to observe occlusal contacts in an orthodontically treated
sample and compared it with a control group using the
T-Scan II. They observed that when analyzed at MIP,
anterior teeth had more occlusal contact and occlusal
p force than the control group, and during protrusive and
lateral movements the disclusion time was higher in the
0.0282* treatment group. Razdolsky et al. [11], Gazit and Liber-
man [12], and Durbin and Sadowsky [13] analyzed occlu-
sal contact distribution after treatment; however, there is
scant literature on the occlusal contacts present during
the finishing stages of treatment.
Tumer, Dincer, Meral [14] stated that after treatment
during the settling phase many changes are not seen; the
number of contacts may increase but the location of the
contacts remains unchanged. Morton and Pancherz [15]
also conducted a study to observe the changes after treat-
ment by natural settling. They found that while occlusion
improved naturally after 2 years in 20 % of the sample, in
72.3 % of the sample it remained the same as was seen at
the time of debonding. In their study they emphasized the
necessity of checking functional occlusion before appli-
ance removal to eliminate unsatisfactory results. Soaita
and Popsor [5] showed in their study on typodonts that
occlusal variabilities exist when pre- and posttreatment
scans taken with the T-Scan III system were compared,
which cannot be detected by clinical inspection, and that
a proper finishing phase is mandatory for obtaining a
functional occlusion for enhanced stability.
In our study we found that at the pre-finishing stage,
complete space closure was achieved and on clinical
inspection the occlusion appeared satisfactory; however,
computerized occlusal analysis using the T-Scan system
revealed unequal force distribution, unequal occlusal
contacts, and a deviated mandibular position. After an
extensive finishing and detailing phase for 2 months, when
the specific problem areas that were identified earlier with
T-Scan were addressed, the occlusal contacts were almost
equal on both sides of the arch in five subjects and showed
marked improvement in four subjects. As stated, not only
the number and contact area are important, but also the
distribution of contacts along the arches statically and

T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment   5
 original article
during function, which is easy to observe with T-Scan;
thus, all attempts were made during the finishing stage to
balance the distribution of occlusal contacts.
As was reported by Riise [16], the biting force also
influences the number of tooth contacts and therefore
the same instruction was given to all patients at both
stages of this investigation to minimize the effect of dif-
ferent biting forces. The occlusal force level distribution
was observed to be greater on the left side in the subjects
at T1. After the settling and finishing phase, a relatively
equal distribution of force levels was observed in most
subjects at T2. de Freitas [17] reported that unbalanced
occlusion is more prone to relapse due to undetected
muscular and articular forces, and therefore before
appliance removal special consideration must be given
to balance the forces on both sides of the dental arch.
Using T-Scan in the pre-finishing stage helped to achieve
a better balance of forces after treatment by making the nec-
essary changes during the finishing and detailing phase.
Changes in mandibular position were also observed at
T2, as 14 subjects had a centric mandibular position and
the number of patients with deviated mandibular posi-
tion reduced to two. Tipton and coworkers [18] reported
that the functional pattern of occlusion plays a significant
role in the stability of the end result; therefore evaluating
functional occlusion at the finishing stages itself helps to
prevent any complications related to the temporoman-
dibular joint etc. at the end of the treatment and leads to
better treatment outcomes.
Cohen-Levy and Cohen [4, 19] also observed the
functional pattern of occlusion after treatment using
the T-Scan system. In a series of cases presented, they
showed that asymmetric forces and contact levels existed
in patients, which could be easily identified using the
T-Scan system and that were corrected by either com-
posite build ups to balance the forces or by giving elas-
tics bonded to labial or lingual buttons as the patients
reported to them after treatment.
Therefore, a T-Scan taken at the finishing stage pro-
vides quantifiable data about occlusal prematurities
during static and dynamic mandibular movements. This
information can be used during the finishing phase when
tooth movement is still possible by adding necessary
bends to the archwire and giving vertical elastics rather
than addressing the functional problems at a later date
when the patient presents with symptoms due to occlusal
imbalances. A 2-month meticulous finishing and detail-
ing phase, in which contacts were evaluated in the verti-
cal and horizontal planes, led to overall better results.
Conclusion
1. Superficial clinical examination and assessment of the
morphologic relationship of the teeth may be insuffi-
cient. A case with a clinically satisfying occlusion may
be functionally unbalanced. Therefore, when appreci-
ating occlusion, correct analysis requires assessment
in the vertical plane.
6   T Scan – An aid in achieving stable occlusion during finishing stages of orthodontic treatment
2. T-Scan is an effective, easy-to-use tool for identifying
occlusal variabilities in the vertical plane rather than
relying on visual inspection or using traditional meth-
ods such as articulating paper or wax sheets, which are
not very accurate.
3. Occlusal problems can be easily and accurately identi-
fied with the T-Scan system in the pre-finishing stage.
This identification of occlusal interferences helps in
tuning the orthodontic tooth movement during the
finishing stage to specifically correct the problems
identified.
4. Occlusal changes required to achieve a functionally
balanced occlusion can be easily done during the fin-
ishing stage by precise placement of finishing bends.
At this stage, tooth movement is still possible, and thus
it is beneficial to address the problems before debond-
ing, rather than later when the patient presents with
symptoms.
5. T-Scan taken at the finishing stages may be particu-
larly helpful for patients who had temporomandibular
joint disorders or facial asymmetry to begin with and
for patients treated by orthognathic surgery so that
stable functional occlusion can be achieved at the end
of active orthodontic treatment.
Compliance with ethical standards
Conflict of interest
V. Seth, A.K. Patil, H. Kidiyoor, and K. Patil state that there
are no conflicts of interest.
All studies on humans described in the present manu-
script were carried out with the approval of the respon-
sible ethics committee and in accordance with national
law and the Helsinki Declaration of 1975 (in its current,
revised form). Informed consent was obtained from all
patients included in studies.
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