Articulating Paper Mark Misconceptions and Computerized Occlusal ...

Articulating Paper Mark 

Misconceptions and Computerized 

Occlusal Analysis Technology: A 

Clinical Brief 

Robert B. Kerstein, DMD 

Former Assistant Clinical Professor 

Department of Restorative Dentistry 

Tufts University School of Dental Medicine 

Boston, Massachusetts 

Private Practice limited to Prosthodontics and Occlusion 

Boston, Massachusetts 

Articulating paper foils and ribbons have been used extensively in clinical practice 

during this century, primarily as occlusal indicators. 1 Their clinical implementation 

requires the operator’s subjective interpretation of the markings to decide which 

contacts are acceptable, which are forceful, or which are time premature. What is 

noteworthy is that the marks’ appearance characteristics and strength of foil tug-back, 

have been described in textbooks on occlusion 2-7 to be descriptive of the occlusal load 

that created the mark. Large, dark marks have been advocated to indicate heavy 

occlusal load, and smaller, lighter marks have been advocated to indicate lesser 

loads. 5-7 Lastly, the presence of many similar-sized marks on neighboring teeth is 

purported to indicate equal occlusal contact intensity, evenness, and time 

1 

Articulating Paper Mark Misconceptions Robert Kerstein, DMD

simultaneity. 2,3 These paper mark appearance perceptions have been trusted by 

practitioners for more than 100 years as a basis with which to select contacts 

requiring correction. 

Published studies about articulating paper are analyses of the physical properties of 

the papers themselves (thickness, composition, ink substrate, plastic deformation), 

and offer no scientific evidence to suggest that articulating paper can measure 

occlusal loads. 8,9 Additionally, Millstein reported that, in the literature, there are no 

proven, scientifically based, proper-use guidelines, for the clinician to follow when 

using articulating paper. 1 

Current research on articulating paper mark size has revealed that the size of an 

articulating paper mark does not describe occlusal forces. 10 An analysis of 600 paper 

markings, made at varying human occlusal loads on epoxy dental casts, determined 

that articulating paper mark size can vary so greatly at a given human occlusal load, 

that an operator would be unable to determine from visual inspection of the markings 

which marks were forceful and which were not. 10 A given mark of virtually any size or 

color intensity (large, small, scratch-like; light, dark) could hold a range of loads (from 

0 N to 500 N) despite its “size” appeareance. 10 The study also showed that similar, 

equally sized marks on neighboring teeth did not represent equal loads.10 The 

authors reported that only 21% of the marks correlated to the applied occlusal load, 

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while 79% of the marks did not describe the applied load that 

imprinted the marks to the casts. 10 

What this means to the clinician is that choosing the marks to 

adjust based on their “size” is highly error-prone. Therefore, in 

a given pattern of marks spread over neighboring teeth, any 

size mark could indicate any load (Figure 1A and Figure 1B). 

Figure 1A 

Articulating paper 

markings of upper 

left PFM fixed 

bridge. Current 

research has shown 

that any size mark 

could contain any 

occlusal load despite 

size and appearance. 

Figure 1B Distribution of mark sizes at various loads for 

the mandibular teeth. Note that at 400 pixels (a given 

mark size) there are seven different loads represented 

(outlined in blue), and at 200 N (a given load) there are 

16 different mark sizes represented (outlined in red) 

(reprinted with permission, Carey et al10). 

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Figure 1B shows how variable the marks and the loads were for all of the mandibular 

markings studied. Note that at 400 pixels (a single mark size) there are seven 

different loads represented, and at 200 N (a single load) there are 16 different mark 

sizes represented. This wide range of mark sizes per load demonstrates why mark 

size is a poor indicator of applied occlusal load. 

Despite the apparent clinical success with the use of paper mark size as an occlusal 

contact selection guide, it appears that using mark size as a force guide can result in 

poor force applications to the occlusion. The occlusal design likely would contain 

unseen force aberrations, regardless of how uniform or “even” the articulating paper 

markings appeared. These unseen aberrations could shorten the life of any 

restoration, and result in postinsertion patient discomfort when the occlusal design is 

not accepted by the prosthetic patient. In this era of immobile dental implants and 

brittle all-ceramic restorative materials, more precise occlusal force control is required 

of all practitioners to ensure material longevity. In a study of 76 maxillary overdenture 

implant prostheses with metallic superstructures incorporated into their design, 70% 

of the prostheses (n = 54) exhibited damage that required repair after 3 years in 

service, despite the authors’ “belief” that they had balanced the occlusion on each 

prosthesis, using articulating paper only to guide the corrections. 11 

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The findings of these 2 studies suggest that the modern clinician needs an occlusal 

contact measuring device that can isolate aberrant occlusal force concentrations and 

time prematurities reliably. As an alternative method to the operator’s subjective 

interpretation of articulating mark appearance, computerized occlusal analysis is 

available to the practitioner (T-Scan® III, Tekscan Inc, South Boston, MA). 

Computerized occlusal analysis has evolved over the past 25 years to become a 

Windows®-based, high-technology occlusal clinical tool, with which to understand 

occlusal contact functional and parafunctional forces, contact timing sequences, and 

occlusal surface interface pressures. The system can be used to diagnose occlusal 

Figure 2A T-Scan III system 

recording handle and sensor. 

Figure 2B USB recording 

handle connected to a computer 

workstation (laptop). 

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problems, identify occlusal contact force and time aberrances, and guide the operator 

through occlusal adjustments during prosthetic and implant dentistry insertions. 12-15 

In 2006, a USB plug-in recording handle and new generation of software were 

released as the T-Scan III occlusal analysis system for Windows (Figure 2A and Figure 

2B). The system displays a recorded occlusal “force movie,” 16 which illustrates the 

various occlusal pressures with colors during playback. The darker colors represent 

low occlusal pressures and the 

brighter colors indicate higher occlusal 

pressures. 

There are numerous researched and 

published clinical applications of 

computerized occlusal analysis. 12- 

15,17,18 There are known uses in 

occlusal therapy, temporomandibular 

disorder treatment, and fixed, 

removable, and implant 

prosthodontics. One of the most 

Figure 3A Image from computerized occlusal 

analysis software showing the occlusal forces 

graded in colors. The “force movie” shows that 

early contact in mandibular closure is at 7.9% of 

total force. Teeth Nos. 10 and 11 are early and 

forceful to their neighbors; they are taller 

columns in height, and are lighter in (green) 

color, whereas their neighbors are shorter in 

height and darker (blue) in color. 

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important applications is the 

system’s ability to describe the 

occlusal contact timing order 

(which cannot be observed in 

articulating paper markings) as 

the different occlusal contacts 

sequentially load. Figure 3A 

through Figure 3C are successive 

“force movie” frames that 

illustrate the evolution of differing 

areas of excessive occlusal force 

in an intercuspated closure over a 

Figure 3B In the middle of mandibular closure 

(0.09 seconds later), the “force movie” shows 

contact is at 39.7% of total force. Teeth Nos. 3 

and 9 are forceful relative to their neighbors; No. 

9 is the light green, tallest column anteriorly, 

and No. 3 is the light orange, tallest column 

posteriorly. 

0.16 second time period. The first overloaded teeth are Nos. 10 and 11 (Figure 3A); 

next, after 0.09 seconds has elapsed, teeth Nos. 3 and 9 become forceful (Figure 3B); 

and lastly, 0.07 seconds later, teeth Nos. 14 and 15 become forceful (Figure 3C). 

These six overloaded teeth were precisely isolated and visualized, making their 

correction simple for the operator to perform. 

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Within the literature, there are 

published proper-use guidelines 

available to the clinician to predictably 

use the technology (unlike articulating 

paper). These guidelines have been 

determined from human subject 

occlusal research performed from the 

1980s to the present day. 19-24 

Paper Mark Misperception: 

A Clinical C 

Example 

Figure 3C Later in same mandibular closure 

(0.07 seconds later), the “force movie” 

shows contact is at 73.6% of total force. 

Teeth Nos. 14 and 15 are forceful relative to 

all teeth; Nos. 14 and 15 have the tallest 

columns of any teeth in the arch, with dark 

orange and red denoting the highest occlusal 

forces. 

An example of a typical paper mark misperception can be 

seen in Figure 1. The previously installed upper left fixed 

porcelain-fused-to-metal (PFM) bridge had been 

uncomfortable for the patient to occlude upon since delivery. 

Over a 3- to 4-month period postinsertion, the patient 

underwent several “paper-only” corrective adjustment 

Figure 1 

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appointments, hoping to alleviate the pain. The pain persisted, however, most likely 

because the problem contact(s) was not isolated predictably, leading the clinician to 

consider endodontics as a solution. 

The patient, instead, underwent a computerized occlusal analysis examination of the 

upper left bridge, which revealed that the damaging occlusal contact was present on 

the distopalatal aspect of tooth No. 15 (Figure 4). This contact was time premature 

Figure 4 Computerized occlusal analyses of PFM bridge seen in Figure 1. Note the 

extreme contact on the distopalatal aspect of tooth No. 15. This contact is the 

smallest paper mark in Figure 1. Also note the low force on tooth No. 11 and large 

corresponding paper mark. 

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and overloaded at only 48% of the patient’s 

total occlusal force (Figure 4; tall red 

column). Note that in Figure 1 and Figure 5, 

this contact is the smallest mark on the 

bridge. Also, the computerized occlusal 

analysis measured tooth No. 11 as low force 

(Figure 4; short blue column), but this area 

has a very large, dark paper marking. This is 

another example of how the appearance of a 

paper mark can be misleading force-wise. 

After identification, the problem contact was 

adjusted and endodontic treatment was 

avoided. Had computerized occlusal analysis 

been used at the time of bridge delivery, the 

problem contact readily would have been 

isolated, and 4 months of patient discomfort 

would have been avoided. 

Figure 5 Articulating paper markings of 

upper left PFM fixed bridge with a circle 

outlining the “problem” occlusal contact 

that was isolated with computer analysis. 

This forceful contact was overlooked 

repeatedly at many postinsertion 

appointments during visual paper mark 

inspection of the occlusal contacts. 

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Summary 

Articulating paper mark size now is understood to be nondescriptive of occlusal loads. 

Many different sized marks can represent the same load, and equal sized marks do 

not represent equal loads. Therefore, choosing paper marks to adjust occlusion, 

based on their relative size, is tantamount to “guessing.” It is important that practicing 

dentists worldwide realize that articulating paper mark size is subject to interpretation 

and a highly unreliable method to use in the assessment of applied occlusal loads. 

Computerized occlusal analysis completely removes the operator’s subjectivity from 

the clinical decision-making process when observing paper markings of various sizes 

and configurations. When using this technology, mark size, mark color depth, “donut”- 

shaped halo contacts, and other color and size mark appearance characteristics are 

ignored as “force indicators,” and used only as “contact locators.” The operator’s 

subjective paper mark misperceptions are replaced with accurate knowledge of the 

true and measured contact order, contact applied load, contact quality, and proper 

contact isolation where problematic. 

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Disclosure 

The author is a clinical consultant for Tekscan Inc. 

References 

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24. 

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