Seminars in Orthodontics 31 (2025) 11−17

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Seminars in Orthodontics
journal homepage:

Orthodontics at the crossroads: A closer look at occlusion,

temporomandibular disorders and the role of cutting-edge technology
€hlhenrich 1, Werner Schupp 3,
Sachin Chhatwani 1,*, Vanessa Knode 2, Stephan Christian Mo
1
Gholamreza Danesh
1
University of Witten/Herdecke, Department of Orthodontics, Alfred-Herrhausen-Str. 45, 58455 Witten, Germany
2
University of Mainz, Department of Orthodontics, Augustplatz 2, 55131 Mainz, Germany
3
Private orthodontic Practice, Hauptstr. 50, 50996 Cologne, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: The field of orthodontics strives to achieve an aesthetic, healthy, and stable occlusion. However, traditional prac-
Centric relation tices often assess occlusion in maximum intercuspidation without adequately considering the biomechanics of the
Jaw tracking systems temporomandibular joint (TMJ), which can lead to overlooking critical occlusal factors. This perspective paper
Temporomandibular disorders
revisits the debate on the role of occlusion in temporomandibular disorders (TMD) and evaluates the efficacy of
TMD
Occlusion
current treatment approaches, emphasizing the limitations of conventional methods and the lack of evidence sup-
porting joint-oriented orthodontics. By integrating jaw tracking systems and digital workflows, a comprehensive
evaluation of dynamic and static occlusion with realistic mandibular movement allows for a more individualized
treatment approach to ensure optimal treatment outcomes.

Introduction be considered as a primary cause or co-factor, they are still regarded as a

risk factor for TMD.3 Walton and Layton state that the role of naturally
The field of orthodontics presents a formidable challenge in the diag- occurring mediotrusive interferences with regard to TMD remains unclear.4
nosis and treatment of achieving a harmonious, esthetic, healthy, and Manfredini et al. suggest that the presence of an MI/CR slide and func-
stable occlusion. Conventionally, in orthodontics, dental models are not tional interferences can be better explained by pain adaptation.5
mounted in articulators, and occlusion is assessed in maximum intercus- A comprehensive review by Cordray reveals a connection between
pidation (MI). This approach often neglects the biomechanics of the tem- condylar displacement from MI to CR and TMD, which eventually is
poromandibular joint. Due to the current state of evidence and the guided by the occlusion.6 Assessment of an MI/CR slide would necessi-
absence of evidence supporting joint-oriented orthodontics, the widely tate joint-oriented articulation of the dental models.7 The research con-
accepted method of diagnosis is to assess patients in their maximum ducted by Manfredini et al. and Cordray highlights the ongoing debate
intercuspidation position. It can be contended that achieving the six surrounding the role of dental occlusion and its potential impact on
keys of normal occlusion, as proposed by Lawrence Andrews should be TMD.5,6 With respect to the relationship between malocclusion and
the sole objective of orthodontic care1, and that dynamic occlusion and TMD, there have been conflicting findings regarding posterior crossbite,
static occlusion in relation to a physiologic condylar position can be anterior open bite, class III, and excessive maxillary overjet. Some stud-
neglected. ies have reported an association between these factors and TMD, while
others have not found a correlation.8-10 As a result, the issue remains
Influence of occlusion on the stomatognathic system controversial.

Occlusion and TMD Occlusion and tooth structure

It should be recognized that occlusal factors have been identified as It should be noted that the influence of premature contacts is not lim-
contributing to the development of temporomandibular disorders ited to TMD but is also strongly associated with the development of non-
(TMD).2 While some research suggests that occlusal factors should not carious cervical lesions (NCCL), suggesting that non-axial occlusal forces

Abbreviations: MI, maximum intercuspidation; TMD, temporomandibular disorders; CBT, cognitive behavioral therapy; CR, centric relation; CT, counseling therapy;
NCCL, non-carious cervical lesions; JTS, jaw tracking systems
* Corresponding author at: University of Witten/Herdecke, Department of Orthodontics, Alfred-Herrhausen-Str. 45, 58455 Witten, Germany.
E-mail address: sachin.chhatwani@uni-wh.de (S. Chhatwani).

https://doi.org/10.1053/j.sodo.2024.06.008

1073-8746/© 2024 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/)

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

occlusal and functional concept.21,26 Additionally, most of the studies

showed that splints had occlusal contacts, but this does not necessarily
mean that the surface was always smooth and flat, which is beneficial in
myopathies to allow for muscular repositioning of the mandible. The
majority of the studies failed to provide details on the adjustments of
splints, as well as overlooked the significance of the clinician’s
expertise.20,25,27,28 All studies had the commonality that the splints
were usually worn at night, with some studies recommending additional
daytime wear mostly of one or two hours.21,23,27,28 Considering the
stated wear time and an average global sleep duration of seven hours29,
it can be assumed that in most cases the splints were only worn for about
seven to nine hours. In contrast the authors’ perspective on optimal wear
Fig. 1. Non-carious cervical lesions, wear facets, class II malocclusion with ante-
time of splints is approximately 22 hours per day, especially in adult
rior crowding − right lateral intraoral situation populations, as the prevalence of awake bruxism in adults and the
amount of occlusal contact time during the day are higher30,31, leading
to constant stimulation of periodontal mechanoreceptors that play a role
and eccentric contacts can result in tooth flexure and strain in the cervi- in neuromuscular pathways.32 Therefore the efficacy of splints worn at
cal region (Fig. 1).11,12 A significant correlation has also been found by night might not be entirely effective, particularly in adults, although
Collio et al. for the prevalence of abfractions in subjects with a discrep- children may be an exception due to their higher prevalence of sleep
ancy in MI and centric relation (CR).13 bruxism.30
The variability in design, follow-up duration, and lack of standard-
Occlusion and periodontal health ized occlusal adjustment protocols challenge the generalizability of find-
ings, underscoring the need for a more nuanced understanding of splint
Research conducted by Rios et al. demonstrated a strong correlation therapy’s role in TMD management.
between occlusal conditions and periodontitis.14 It is essential to recog- In a network meta-analysis conducted by Al-Moraissi et al., a sub-
nize that occlusal interferences can exacerbate periodontal compromised stantial reduction in post-treatment pain intensity was demonstrated
situations, leading to pathologic tooth migration.15 It has been described through the use of hard stabilization splints.33 The use of additional
that mediotrusive interferences should be avoided in therapeutic con- counseling therapy (CT) has been found to result in a minor level of
cepts to prevent pulpal and periodontal complications, as well as struc- increased pain reduction.33 It is essential to acknowledge the impact of
tural and mechanical issues.4 CBT and CT, as these are effective modalities in addressing pain-related
According to a rat model, it was demonstrated that following ortho- issues.34,35 According to a systematic review conducted by Liu et al., the
dontic tooth movement, the emergence of occlusal interferences or literature provided insufficient evidence regarding CBT. The studies con-
insufficient contacts resulted in increased inflammation of the periodon- tained within the literature showed high heterogeneity, substantial dif-
tal tissue and bone resorption. Furthermore, it was determined that ferences in follow-up periods, and controls, which led the authors to
these occurrences were linked to a higher likelihood of relapse. Conse- decline performing a meta-analysis.36
quently, it was recommended that occlusal adjustments should be car- Our standard protocol for treating temporomandibular disorders
ried out subsequent to active orthodontic treatment.16 with muscular origin, with a possible causality related to altered joint
The findings emphasize that occlusal factors have an impact on vari- function37, typically involves the use of oral splint therapy, which fea-
ous aspects of the stomatognathic system, which underscores the neces- tures a height depending on a 2mm disclusion of the posterior molars.
sity of integrating comprehensive treatment planning approaches The splint is designed with anterior and canine guidance, and its surface
considering not only esthetics but also function. is smooth and flat, featuring one centric contact at each premolar and
molar and no centric contacts in the frontal area (Fig. 2). Patients are
Critical review of current literature on temporomandibular required to wear the splint for at least 22 hours per day, and occlusal
disorders adjustments are made according to the described pattern on a weekly
basis until the occlusal contacts remain stable. This approach differs
There are multiple treatment options available for TMD, including from the aforementioned literature. It is crucial to mention that the
cognitive behavioral therapy (CBT), physiotherapy, splint therapy, TMD therapy is an entity on its own but often followed by a subsequent
occlusal equilibration, surgical procedures, pharmacotherapy, and com- orthodontic treatment as alterations of the occlusion can be caused by
bined treatment.17 the TMD therapy (Fig. 3).
The British Medical Journal has issued a recent guideline that sug-
gests CBT and mobilization techniques as more suitable treatment The joint-oriented treatment workflow in digital orthodontics
options for individuals with chronic TMD, rather than splint therapy.18
The guideline18 specifically refers to a systematic review19 showing low A main principle is at first instance not to cause any harm − “primum
evidence and inefficiency of oral splints in reducing pain when com- nihil nocere”. The question that presents itself is which course of action
pared to no or minimal treatment. inflicts more harm: neglecting to address a risk factor for pathology or
A critical examination of the systematic review reveals that the find- even creating risk factors or adhering to established principles and pro-
ings are not surprising and that some concerns should be raised. The viding anterior and canine guidance to prevent interfering contacts? The
studies included in the review were highly heterogeneous, and when authors’ perspective on the matter is clear as occlusal interferences also
pooled together, they do not allow for a general conclusion about the contribute significantly to the formation of various other conditions.
efficacy of occlusal splints. The duration of follow-up and active study To prevent negative consequences from premature contacts, the
time varied greatly, ranging from two weeks20 to 12 months21, and even orthodontic models should at least be mounted with a CR record prior
the splint design was highly variable, ranging from jig appliances20,22, the removal of orthodontic appliances to aim for a mutually protected
vacuum-formed splints23, Michigan splints20,24 to flat occlusal splints25. occlusion. Ideally, treatment should also be initiated in this manner.
Not all studies provided a generalized statement regarding the presence Traditionally this was accomplished by utilizing plaster models, CR
or absence of anterior and canine guidance without interference during registration and determination of the hinge axis either arbitrarily or con-
excursive movements, leaving room for interpretation regarding the ventionally to mount the models into an articulator. The incorporation

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

Fig. 2. A − Occlusal view of a splint with flat posterior

surfaces with single static contacts for each tooth (red)
and anterior and canine guidance (green); B- intraoral
left lateral view of inserted splint

Fig. 3. A − sagittal occlusal relationship prior to splint ther-

apy, B − sagittal occlusal relationship after splint therapy

Fig. 4. Scanned articulated plaster casts in CR imported to OnyxCeph (Image Instruments GmbH, Chemnitz, Germany); A − frontal view, B − lateral view, C- upper jaw
occlusal view with contact points, D − lower jaw occlusal view with contact points

13

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

Fig. 5. Visualization of the calculated hinge axis and the arbitrary axis − Twim Software (Modjaw, Villeurbanne, France)

of intraoral scanners in orthodontics has led to the potential benefits of a aid in providing a reconstruction of individual patient movement and
full digital workflow. Historically, the joint-oriented full digital work- thereby a more realistic treatment approach40, with accurate informa-
flow in orthodontics was more than challenging. One innovative tion of the intermaxillary relationship41, and also allow the full digital
approach for treatment diagnosis and dynamic evaluation of mandibular workflow for joint-oriented treatment modalities in dentistry.
movements in real time required the utilization of cone-beam computed The technology employed in JTS varies, with magnetometry, ultra-
tomography which resulted in additional radiation exposure.38 Further- sound, photometry, and infrared optical systems being the primary
more, the available system at that time (Sicat, Bonn, Germany)39 did not options currently available.42
allow to perform orthodontic setups and could therefore only be used as The Modjaw device is based on photometrics and is designed to be
diagnostic tool. Alternatively mounted plaster models had to be scanned used with a headband that includes four markers. The concept of the
in a modelscanner capable of scanning with articulators (e.g. Zirkonzahn jaw tracking system using markers originates from the field of animation
GmbH S600 Arti, Gais, Italy) with the obtained digital models at CR to film, where human subjects were outfitted with markers and their move-
be imported into an orthodontic treatment planning software (Fig. 4). ments were recorded. The motions were used to animate characters in films.
Utilization of jaw tracking systems (JTS) like Modjaw (Modjaw, Vil-
leurbanne, France) or DMD (Ignident GmbH, Ludwigshafen, Germany)

Fig. 6. Intraoral model scans with relationship of pre- and post calculated axis.
The blue arrow shows the arbitrary hinge axis and the yellow arrow shows the Fig. 7. Rotation around the true hinge axis into first contact position referred as
new calculated hinge axis − Twim Software (Modjaw, Villeurbanne, France) centric relation − Twim Software (Modjaw, Villeurbanne, France)

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

Fig. 8. Changes in occlusal contact points, A: maximum intercuspidation MI, B: centric relation CR − Twim Software (Modjaw, Villeurbanne, France)

Fig. 9. Superimposition on upper jaw and color coded heat map for lower jaw changes from maximum intercuspidation MI to centric relation CR; A − right lateral
view, B − frontal view, C − left lateral view

The system also includes a paraocclusal bitefork, which is positioned After tooth segmentation and virtual model preparation, the
at the lower teeth using self-curing composite for provisional crowns imported hinge axis can be visualized, and the jaw can be rotated around
and bridges (Structur 3, VOCO GmbH, Cuxhaven, Germany). It is impor- it during treatment planning for precise joint-oriented orthodontics
tant to ensure that no composite is in contact with the opposing teeth (Fig. 10). The CR position is now the starting point of orthodontic treat-
during maximum intercuspidation or excursive movements. Another ment, and the teeth should be aligned accordingly. The protocol
holder with markers is attached to the bite fork, and the stereocamera is described is the minimal protocol needed for joint-oriented orthodon-
adjusted based on the distance and height. To record dynamic move- tics. In the finishing phase, the protocol should be extended to include
ments, the system is calibrated by providing reference points for the dynamic protrusive and laterotrusive movements, as well as mouth
arbitrary hinge axis and subnasale and for four occlusal points in the opening and closure, to check for interferences and finish the case
lower dentition. accordingly.
The true hinge axis is calculated by asking the patient to open and The importance of achieving a functional occlusion without interfer-
close their mouth by 5-10mm a few times, while instructing them not to ence cannot be overstated, as it is essential for optimal treatment out-
touch their teeth during closure to minimize the influence of neuromus- comes. It is possible that occlusal adjustments or restorations may be
cular engrams.43 Alternatively, the clinician can guide this movement. necessary to ensure a successful outcome (Fig. 11).
As the rotational condylar movement is recognized by the software,
the true hinge axis can be determined, and the models will be oriented Conclusion
accordingly (Figs. 5, 6). Then, the clinician will actively rotate the lower
jaw to the first contact positions, which will be referred to as the CR The integration of digital technological advancements like jaw track-
position (Fig. 7). The mandibular position in CR and MI is different, and ing systems in orthodontics enables a comprehensive digital treatment
this can be visualized by showing changes in occlusal contacts (Fig. 8) workflow and an accurate evaluation of dynamic and static occlusion.
and by exporting the CR models into the orthodontic treatment software Research on the influence of occlusal factors suggest that interferences
with superimpositions on the upper jaw, displaying the difference in jaw can have a negative effect on the condition of the stomatognathic sys-
position in color-coded heat maps (Fig. 9). tem. Orthodontic treatment goals should therefore consider joint-

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

Fig. 10. Segmented models for orthodontic treatment with the true hinge axis in the treatment planning software OnyxCeph (Image Instruments GmbH, Chemnitz,
Germany)

Fig. 11. Occlusal contacts after finishing a case with anterior

and canine guidance after orthodontics and occlusal rehabilita-
tion with flowable composite injection method; A − upper jaw
occlusal view, B − lower jaw occlusal view

oriented dynamic occlusion and principles of a mutually protected Funding

occlusion should not be disregarded.
No funding or grant support received.

Consent for publication Author contributions

Only anonymised patient data was used and no patient data reveal- All authors attest that they meet the current ICMJE criteria for
ing the identity of the patients is published therefore consent of publica- authorship.
tion can be waived.
Declaration of competing interest

Availability of data and materials The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
All data are available on request. the work reported in this paper.

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S. Chhatwani et al. Seminars in Orthodontics 31 (2025) 11−17

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