|Year : 2019 | Volume
| Issue : 3 | Page : 252-256
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
|Date of Submission||26-Feb-2019|
|Date of Acceptance||20-Apr-2019|
|Date of Web Publication||30-Sep-2019|
Dr. Ancy V Ignatius
Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Road No. 5, Kamala Nagar, Dilsukhnagar, Hyderabad, Telangana - 500 060
Source of Support: None, Conflict of Interest: None
| 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
|How to cite this article:|
Komali G, Ignatius AV, Srivani G S, Anuja K. T-scan system in the management of temporomandibular joint disorders – A review. J Indian Acad Oral Med Radiol 2019;31:252-6
|How to cite this URL:|
Komali G, Ignatius AV, Srivani G S, Anuja K. T-scan system in the management of temporomandibular joint disorders – A review. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2022 May 28];31:252-6. Available from: https://www.jiaomr.in/text.asp?2019/31/3/252/268276
| 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.
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.
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 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.
Maness et al. developed a new computerized system known as T-scan that can record occlusal forces easily and conveniently. 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 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). 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.
| 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]:
|Figure 2: Patient biting onto the sensor for recording different functional mandibular movements|
Click here to view
- 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 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.
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 wise within each arch which helps in assessment of bilateral time and force simultaneity, bilateral force equality, and the overall occlusal force distribution. 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.
|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|
Click here to view
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, compared to occlusal procedures governed by subjective interpretation.
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. In 2002, Hirano et al. performed anin 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.
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.
| 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.,,, 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 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.,
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.
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.
|Figure 4: The occlusion time (OT; A–B) and disclusion time (DT; C–D) in the bottom graph|
Click here to view
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 incisors are in contact. 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. 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.,,,
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.
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.
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 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.
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.
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.
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.
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 technology has brought relief of symptoms in about a week to 10 days time.
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.
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.,
| 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
Conflicts of interest
There are no conflicts of interest.
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