[Downloaded free from http://www.jiaomr.in on Thursday, May 14, 2020, IP: 150.129.88.

140]

Review Article

T‑Scan System in the Management of Temporomandibular Joint

Disorders – A Review
Garlapati Komali, Ancy V. Ignatius, G. Swetha Srivani, Kammari Anuja
Department of Oral Medicine and Radiology, PMVIDS, Hyderabad, Telangana, India

Abstract
Temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals worldwide. TMD is a musculoskeletal
disorder within the masticatory system presenting with typical signs and symptoms of pain, limited mouth opening, joint sounds, mandibular
deviation, and chewing disability. Pain is the most important symptom of TMD which drives the patient to seek medical help. The etiology of
TMD is complex and multifactorial. The role of dental occlusion as an etiological factor for TMD has been hypothesized by several authors.
A balanced dental occlusion plays an important role for the healthy functioning of the masticatory system. Premature occlusal contacts and
occlusal‑articulating interferences cause occlusal trauma which can induce changes in the tooth‑supporting tissues (the mucosa, periodontal
tissues, and bone), in the muscles of mastication and the temporomandibular joint. In dental practice, articulating paper has been established
as the most widely used diagnostic aid to mark the contact points between the maxillary and mandibular teeth. The articulating paper can
readily highlight the occlusal contacts; however, it can neither accurately quantify the intensity nor measure the magnitude of the generated
occlusal forces. T‑scan computerized occlusal analysis technology eliminates the process of subjective interpretation of occlusal contacts
obtained using articulating paper marks and precisely pinpoints the excessively forceful contact locations and displays them for analysis in a
colourful three‑dimensional view thus helping the diagnostician to understand the overall occlusal force distribution. This article deals with
T‑scan system and its role in temporomandibular disorders.

Keywords: Myofascial pain, occlusal interferences, temporomandibular disorders

Introduction
The masticatory system is made up of the teeth,
periodontal tissues, masticatory muscles, and
temporomandibular joint (TMJ). A balanced dental occlusion
plays an important role in the healthy functioning of the
masticatory system.[1]
Normal occlusal and the articular relations between the jaws
ensure balanced distribution of the generated forces in them
during mastication. Any premature occlusal contacts and
occlusal‑articulating interferences cause occlusal trauma that
can induce changes in the tooth‑supporting tissues (the mucosa,
periodontal tissues, and bone), in the muscles of mastication
and the TMJ.[2]
Earlier, the concept of occlusion was approached by studying
the static relationship between teeth using articulating paper,
shim stocks, occlusal waxes, and silicone impressions. In
common dental practice articulating paper has been established
Access this article online
Quick Response Code:
Website:
www.jiaomr.in
DOI:
10.4103/jiaomr.jiaomr_46_19
as the most widely used diagnostic aid to mark the contact
points between the maxillary and mandibular teeth. The
articulating paper can readily highlight occlusal contacts,
but cannot accurately quantify the intensity or measure the
magnitude of the generated occlusal forces. The intensity of
the occlusal forces is interpreted based on the size of the mark
area of the articulating paper.[2]
Maness et al. developed a new computerized system known as
T‑scan that can record occlusal forces easily and conveniently.[3]
The evolution of the T‑scan technology over the past 30 years
had its beginning with T‑scan I in 1984, then T‑scan II for
Address for correspondence: Dr. Ancy V. Ignatius,
Panineeya Mahavidyalaya Institute of Dental Sciences and Research
Centre, Road No. 5, Kamala Nagar, Dilsukhnagar, Hyderabad,
Telangana ‑ 500 060, India.
E‑mail: ancyvi@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Komali G, Ignatius AV, Srivani GS, Anuja K.
T-scan system in the management of temporomandibular joint disorders – A
review. J Indian Acad Oral Med Radiol 2019;31:252-6.
Received: 26‑02‑2019   Accepted: 20‑04‑2019   Published: 30-09-2019

252 © 2019 Journal of Indian Academy of Oral Medicine & Radiology | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.jiaomr.in on Thursday, May 14, 2020, IP: 150.129.88.140]
Komali, et al.: T‑scan system in the management of TMDs
Windows in 1995, to T‑scan III (software versions 5, 6, and 7)
in 2004, later with development of Turbo recording in 2008,
to the 2014 version known as T‑scan 8 (Tekscan Inc., South
Boston, MA, USA).[4] The T‑scan handpiece model got updated
in 2015 as T‑scan Novus (software version 9.1) and the latest
updated one being T‑scan v10 software version introduced
in 2018.[5]
T‑scan 8 Version Specifications
This computerized system, named T‑scan, consists of a
recording handle, sensor holder, HD sensors, and USB port
to connect to computer/laptop [Figure 1]. The HD sensor’s
structural design consists of two layers of Mylar encasing
a grid of resistive ink rows and columns printed between
them. The sensors are manufactured in two sizes; large for
broad mediolateral and long anteroposterior dental arches
and small for thin mediolateral and short anteroposterior
dental arches.
The T‑scan system features are as follows:
• Turbo recording: The T‑scan III system allows a clinician
to record incremental sensor scanning in a short time span
of 0.003 s.
• Force outliers: Force outliers are individual tooth contacts
with high relative force at any given moment during a
mandibular closure.
• Individual tooth timing: Tooth timing of selected tooth
shows its individual force within a force versus time graph
for comparison with other teeth.
• Integration of the T‑scan III with an electromyography
system: The T‑scan III system can be linked through
software integration with the electromyography system.
Clinically, the T‑scan 8 system is used to record different
functional mandibular movements [Figure 2]:
• Centric relation: This records centric relation prematurity.
• Multi‑bite: This records two or more repeated self‑closures
made in patient’s habitual intercuspation. This records
the occlusion time (OT) and also captures the occlusal
Figure 1: T‑scan device
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 3  ¦  July-September 2019
contact closure sequence from first contact to static
intercuspation, and then past static intercuspation onto
maximum intercuspation.
• Excursive functional movements – lateral and
protrusive: This recording is used to assess the posterior
disclusion time (DT) that occurs during mandibular
excursions.
• Clenching and grinding: This records painful occlusal
contacts during chewing and eating. The patient is
instructed to first self‑close firmly into their habitual
intercuspation, and then grind back and forth across their
teeth with the sensor interposed.
• Digital occlusal force distribution patterns: This records
excess occlusal force concentrations in the arch for which
the patient is instructed to bite firmly with maximum
intercuspation on the recording sensor and then open to
disarticulate their teeth.
Computerized occlusal analysis technology records the
sequence of closure from the first point of contact into
maximum intercuspation. These closure data can be used to
analyze and interpret the time required for the teeth to reach
complete intercuspation, while the force mapping data can
be used to objectively locate forceful occlusal contacts. The
dynamic three‑dimensional and two‑dimensional graphic
display serves as a comprehensive educational tool for patient
understanding, while providing the clinician with objective,
quantifiable occlusal force and timing data that assist in
performing precise and targeted occlusal diagnoses and
corrective adjustments.[4]
T‑scan occlusal force and timing data eliminate subjective
interpretation of contacts using articulating paper marks and
precisely pinpoint the excessively forceful contact locations
and display them for analysis in a three‑dimensional view, as
differing height columns ranging from low force, displayed as
small blue columns, up to the high force, displayed as tall red
and pink columns [Figure 3]. The two‑dimensional force view
illustrates the percentage of force on individual teeth, quadrant
Figure 2: Patient biting onto the sensor for recording different functional
mandibular movements
253
[Downloaded free from http://www.jiaomr.in on Thursday, May 14, 2020, IP: 150.129.88.140]
Komali, et al.: T‑scan system in the management of TMDs
wise within each arch which helps in assessment of bilateral
time and force simultaneity, bilateral force equality, and the
overall occlusal force distribution.[4] This visual display not only
improves the accuracy of the clinician’s corrective adjustment
results but also engages the patient’s attention and curiosity.
The patient can comprehend the areas of high force that are
represented in the differing colors (such as green describing
moderate force; yellow describing moderately high force;
red describing high force; and pink describing an unknown
amount of high force), allowing them to visually evaluate
their own nonuniform occlusal force distribution [Figure 3].
This aids in the clinical case management with patient’s active
cooperation, understanding, and acceptance for the needed
corrective treatment.[4]
Since its inception, the T‑scan technology underwent rigorous
peer review and validated its reliable relative occlusal force
reproduction and time measurement capabilities. The T‑scan
has been part of controlled studies that have proven its ability
to provide an improved occlusal treatment,[6] compared to
occlusal procedures governed by subjective interpretation.[4]
A study was conducted by Garcia Cartagena et al. in 1996 on
31 subjects and has concluded that the T‑scan is a reliable, easy,
fast, and convenient method for recording tooth contacts.[7]
In 2002, Hirano et al. performed an in vitro study on the
accuracy and repeatability of the T‑scan II system. The authors
studied the accuracy of time recordings, the linear relationship
between loaded forces and force recording output, the pressure
sensitivity, and the variability of force recordings during
repeated sensor loading. The authors reported that the time
recordings were proportional to the actual real‑time of the
recorded event, and that the force recordings were acceptably
precise with a linear relation. They also found that the stability
of the sensor with repeated force recording was acceptable,
and that the level of force stayed constant during repetition.[8]
A study conducted by Bozhkova in 2016 on 30 patients,
to evaluate the T‑scan III system capabilities in registering
the occlusal contacts during mastication, concluded that the
T‑scan system provides the only accurate way to determine
and evaluate the time sequence and force of occlusal contacts
by converting the qualitative data into quantitative data and
displaying them digitally.[2]
T‑Scan System in TMJ Disorders
Optimal dental care is based on making an accurate diagnosis,
followed by patient counselling regarding their problems and
possible solutions, prior to designing an individualized and
appropriate treatment plan. The occlusal analysis plays an
important role in the comprehensive dental examination.
The etiology of temporomandibular disorder (TMD) is
multifactorial. [9‑12] Although occlusion is considered to
play a pivotal role in initiation of disorder, this is not being
conclusively demonstrated. Temporomandibular dysfunction
is mostly due to functional malocclusion rather than
`254 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 3  ¦  July-September 2019
morphological malocclusion. TMDs arise due to occlusal
instability by causing excessive load on the masticatory system.
The influence of occlusion as an etiological factor for TMD is
still in the state of controversy. Therefore, a correct approach
toward understanding the role of dynamic occlusion is very
critical for differentiating between the normal and pathological
occlusal parameters. T‑scan system (Tekscan Inc.) accurately
identifies the location of premature occlusal contacts that are
not always visualized by direct clinical observation, or with ink
ribbon markings. The T‑scan system enables the clinician to
quantitatively evaluate the occlusal contacts during continuous
mandibular movement and can also provide functional
occlusion information such as OT and DT.[9,13]
The T‑scan I technology (T‑scan 2000; Tekscan Inc.) was
introduced to the field of TMDs in 1984 and paved a path for
research‑supported studies in favor of dental occlusion as an
etiological factor for TMD. Because the T‑scan I could measure
occlusal contact timing sequences in 0.01 s increments, a new
occlusal functional movement parameter, known as posterior
DT, was isolated which measured prolonged excursive
movement durations.[14]
The OT (A–B) [Figure 4] is the elapsed time in seconds,
measured from the first tooth contact until the last tooth
contacts, as a patient closes all their teeth together from
completely open (no tooth contact) to the beginning of static
intercuspation (the A–B increment). Static intercuspation
always occurs before the patient achieves maximum
intercuspation (MIC) force levels. The OT describes the degree
of bilateral time simultaneity present in a patient’s occlusion.
It has been deemed ideal when the OT is ≤0.2 s in duration.[4]
The DT (C–D) [Figure 4] is the elapsed time in seconds,
measured from the beginning of an excursive movement
made in one direction (right, left, or forward) with all teeth
in complete intercuspation through until only canines and/or
Figure 3: The three‑dimensional view of the occlusal analysis shown as
differing height columns ranging from low force, small blue columns;
moderate force, green columns; and the high force, tall red columns
[Downloaded free from http://www.jiaomr.in on Thursday, May 14, 2020, IP: 150.129.88.140]
Komali, et al.: T‑scan system in the management of TMDs
Figure 4: The occlusion time (OT; A–B) and disclusion time (DT; C–D)
in the bottom graph
incisors are in contact.[14] The DT can be measured in all three
different mandibular excursive movements.
The DT describes the quality of the anterior guidance
mechanism present in a patient’s occlusion. It has been
deemed ideal when it is ≤0.5 s in duration and is deemed to
be prolonged when it is >0.5 s.[14] Demonstrating immediate
posterior disclusion is considered a desirable component of
occlusal health and advocated to be a requirement for an
optimum occlusal design.
Studies have shown that prolonged DT can be an instigator
of excursive muscle hyperactivity and muscular TMD
symptoms.[14‑17]
It was in 2004 that T‑scan III/BioEMG synchronization was
introduced which represented a major advancement in the
study of occlusal function as the dynamic occlusal contact
information and its corresponding muscle activity response
could be recorded simultaneously.[18]
The BioEMG electromyography system records electrical
(biopotential) activity from eight muscles simultaneously.
Bilaterally, the anterior temporalis, masseter, digastric, and
sternocleidomastoid muscles can be measured. Kerstein and
Radke conducted a study to investigate the correlation between
activity of masseter and anterior temporalis muscles and the
DT. In their study, 45 subjects (29 female and 16 male) with
TMD were selected and their right and left DTs were recorded
with T‑scan III. Simultaneously, the electromyographic activity
of bilateral masseter and anterior temporalis muscle was also
recorded with BioEMG III (n = 180 muscles). They concluded
that there was significant activity reduction in all four muscles
after reduction in the pretreatment prolonged DT to less than
0.4 s. Hyperactivity in muscle causes lactic acid accumulation,
muscular ischemia, and chronic TMD symptoms.[19]
In 2012, Wang and Yin performed an analysis of occlusal risk
factors associated with TMDs in 31 patients with complete
natural dentition and angle class I occlusion who exhibited
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 3  ¦  July-September 2019
TMD and compared them with 31 healthy non‑TMD control
subjects. The occlusal recordings were performed using the
T‑scan II system. Among the various parameters recorded and
compared with the control subjects, the TMD subjects had a
significantly higher frequency of premature contacts (16/32,
50.0%) and greater bilateral asymmetry in the occlusal force.
Furthermore, prolonged OT and DT were also observed in
the TMD subjects. All these data suggest that there was a
significant association between occlusal stability and TMD
in young adults.[20]
A case–control study was conducted in 2013 by Haralur on
100 patients, divided into two groups. T‑scan analysis using
T‑scan III system was done in the control group (group I) and
TMD group (group II). The study has shown that group I had
0.689, 0.9136, 0.7952, and 0.9794 s of clusion, left, right, and
protrusive DT, respectively, compared to the corresponding
1.862, 1.7995, 1.6978, and 1.9296 s for group II. Statistically
significant difference (P ≤ 0.05) was found between the mean
values of both groups indicating that occlusal interferences
were found to be highly influential in TMD etiology. The study
suggested that patients with TMD had prolonged occlusion and
DTs compared with healthy TMJ patients.[21]
In spite of its diverse etiology, occlusal instability has long
been considered an important etiological factor in myofascial
pain. Occlusal equilibration had been advocated by numerous
authors as a successful treatment modality for myofascial
pain. T‑scan (Tekscan Inc.) guided occlusal adjustment
procedure with the primary therapeutic goal of decreasing
the time required for all premolars and molars to disclude
from each other during mandibular excursions (known as DT
reduction, <0.4 s/excursion) has been shown to be successful
in treating myofascial pain patients. Shortening the DT can be
accomplished with the immediate complete anterior guidance
development (ICAGD) enameloplasty or by an addition
procedure performed with the aid of computerized occlusal
analysis that records real‑time measurements of excursive
movements as dynamic force movies.[9]
A study was conducted in 2014, by Prafulla Thumati on
51 patients, to evaluate the effect of reduced DT in lateral
excursions in patients with Myofascial pain dysfunction
syndrome (MPDS). The results clearly indicated that ICAGD
protocol reduces musculoskeletal‑based symptoms of patients
with MPDS, and this protocol can prove beneficial for the
clinical treatment success.[22]
Another study was conducted in 2015, by Prafulla Thumati
on 100 patients, to evaluate the effect of occlusal equilibration
using ICAGD technique on the subjective symptoms of
myofascial pain. The primary objective was to reduce the
anterior DT to <0.4 s and the secondary objective was to reduce
the signs and symptoms of myofascial pain.
This study concluded that the treatment of these 100 patients
with occlusal equilibration using digital analysis of occlusion
using T‑scan, electromyography, and joint vibration analysis
255
[Downloaded free from http://www.jiaomr.in on Thursday, May 14, 2020, IP: 150.129.88.140]
Komali, et al.: T‑scan system in the management of TMDs
technology has brought relief of symptoms in about a week
to 10 days time.[23]
Thumati and Thumati conducted a study in 2016 on 100 cases,
to evaluate the longevity of reduced DT in treatment of
myofascial pain dysfunction symptoms using T‑scan‑based,
ICAGD coronoplasty. The results showed that this measured
occlusal adjustment reduces the muscle hyperactivity of
myofascial pain.[9]
A recent study was done by Dzingute et al. on 44 patients with
TMD using T‑scan II computerized occlusal analysis system.
The patient’s occlusion and static occlusal parameters such
as center of occlusal force, asymmetry index of maximum
occlusal force, and OT were recorded. The results showed
existence of relationship between TMD and static occlusion
parameters. The values of the center of the occlusal force
distance and the asymmetry index of occlusal force in patients
with TMD with pain in the TMJ were significantly higher than
in the control group.[24,25]
Conclusion
The invention of modern diagnostic tool like T‑scan
computerized occlusal analysis system that can measure
relative occlusal forces precisely in real time is a boon in the
modern era of dentistry. The sensitivity and specificity of the
device have been significantly improved over the years in
recording occlusal interferences. It has been a reliable indicator
of occlusal interferences for the precise identification and
occlusal equilibration to achieve ICAGD in the management
of TMDs, thus contributing to success of treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Agbaje JO, Casteele EV de, Salem AS. Assessment of occlusion with
the T‑Scan system in patients undergoing orthognathic surgery. Sci Rep
2017;7:53‑6.
2. Bozhkova TP. The T‑SCAN system in evaluating occlusal contacts.
Folia Medica 2016;58:122‑30.
3. Maness WL, Benjamin M, Podoloff R, Bobbick A, Golden RF.
Computerized occlusal analysis: a new technology. Quintessence Int
1987;18(4):287‑92.
4. Kerstein RB. Handbook of Research on Computerized Occlusal
Analysis Technology Applications in Dental Medicine. Hershey, PA:
IGI Global Publishers; 2015.
`256 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 3  ¦  July-September 2019
5. Tekscan. 2018. Dental. [online] Available from: https://www.tekscan.
com/dental. [Last accessed on 2019 Feb 20].
6. Kerstein RB, Lowe M, Harty M, Radke J. A force reproduction analysis
of two recording sensors of a computerized occlusal analysis system.
Cranio 2006;24:15‑24.
7. Garcia Cartagena A, Gonzalez Sequeros O, Garrido Garcia VC. Analysis
of two methods for occlusal contact registration with T‑Scan system.
J Oral Rehabil 1996;24:426‑32.
8. Hirano S, Okuma K, Hayakawa I. In vitro study on the accuracy
and repeatability of the T‑Scan II system. Kokubyo Gakkai Zasshi
2002;69:194‑201.
9. Thumati P, Thumati RP. The effect of disocclusion time‑reduction
therapy to treat chronic myofascial pain: A single group interventional
study with 3 year follow‑up of 100 cases. J Indian Prosthodont Soc
2016;16:234‑41.
10. Conti P.C, Ferreira PM, Pegoraro LF, Conti JV, Salvador MC.
A cross‑sectional study of prevalence and etiology of signs and
symptoms of temporomandibular disorders in high school and university
students. J Orofac Pain 1996;10:254‑62.
11. Marklund S, Wanman A. Risk factors associated with incidence and
persistence of signs and symptoms of temporomandibular disorders.
Acta Odontol Scand 2010;68:289‑99.
12. Akoren AC, Karaagaclioglu L. Comparison of the electromyographic
activity of individuals with canine guidance and group function
occlusion. J Oral Rehabil 1995;22:73‑7.
13. Kahn J, Tallents RH, Katzberg RW, Ross ME, Murphy WC. Prevalence
of dental occlusal variables and intraarticular temporomandibular
disorders: Molar relationship, lateral guidance, and nonworking side
contacts. J Prosthet Dent 1999;82:410‑15.
14. Kerstein RB, Wright N. An electromyographic and computer analysis of
patients suffering from chronic myofascial pain dysfunction syndrome,
pre and post‑treatment with immediate complete anterior guidance
development. J Prosthet Dent 1991;66:677‑86.
15. Kerstein RB, Chapman R, Klein M. A comparison of ICAGD (Immediate
Complete Anterior Guidance Development) to “mock ICAGD” for
symptom reductions in chronic myofascial pain dysfunction patients.
Cranio 1997;15:21‑37.
16. Kerstein RB, Tarantola G. Clinical Cases in Restorative and
Reconstructive Dentistry. Hoboken, NJ: Wiley‑Blackwell;
2010;391‑431.
17. Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity
decreased by measured anterior guidance development. Cranio
2012;30:243‑54.
18. Kerstein RB. Combining technologies: A computerized occlusal
analysis system synchronized with a computerized electromyography
system. Cranio 2004;22:96‑109.
19. Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity
decreased by measured anterior guidance development. Cranio
2012;30:243‑54.
20. Wang C, Yin X. Occlusal risk factors associated with temporomandibular
disorders in young adults with normal occlusions. Oral Surg Oral Med
Oral Pathol Radiol 2012;114:419‑23.
21. Haralur SB. Digital evaluation of functional occlusion parameters and
their association with temporomandibular disorders. J Clin Diagn Res
2013;7:1772‑5.
22. Thumati P, Manwani R, Mahantshetty M. The effect of reduced
disclusion time in the treatment of myofascial pain dysfunction
syndrome using immediate complete anterior guidance development
protocol monitored by digital analysis of occlusion. Cranio. 2014;32.
23. Thumati  P. The influence of immediate complete anterior guidance
development technique on subjective symptoms in myofascial pain
patients: Verified using digital analysis of occlusion  (Tek‑scan) for
analysing occlusion: A 3 years clinical observation. J Indian Prosthodont
Soc 2015;15:218‑23.
24. Dzingute A, Pileicikiene G, Baltrusaityte A, Skirbutis G. Evaluation
of the relationship between the occlusion parameters and symptoms
of the temporomandibular joint disorder. Acta Medica Lituanica
2017;24:167‑75.
25. Dzingute A, Pileicikiene G, Baltrusaityte A. Digital occlusal evaluation in
patients with temporomandibular joint disorders. Mol Med Ther 2017;1:8‑13.