Case Report

Incidence of headaches related to occlusion

and bite force imbalance: a case study
Ben A. Sutter
Private Practice, TMD Headache Oregon, Eugene, OR, USA

Aims: The purpose of this case report is to share an incidence where a bite force imbalance and occlusal
interferences contributed to chronic daily headaches.
Methods: A TekScan digital occlusal analyzer was used to evaluate the bite and systematically guide
alterations to the patients occlusion.
Results: After the bite was adjusted and optimized, the patient reported a decrease in her headaches.
Shortly afterward, she sustained trauma to her face that altered the way her bite came together.
Via physical therapy modalities to heal the muscle, occlusion was restored to the pre-trauma relationship.
Conclusions: Once the patients bite was balanced and the interferences removed, the headaches were
greatly improved.
Keywords: TMD, TMJ, Headaches, Occlusion

Introduction which can result in migraines.11 Reducing this

An increasing amount of data suggests that head-
aches are related to malocclusion, and often are a
component of temporomandibular disorders
(TMDs).19 Even though scientific evidence does
not definitively corroborate this, an experienced clin-
ician who treats these types of patients knows that an
apparent connection does exist. In 2007, Cooper and
Kleinberg6 examined 4528 TMD patients for signs
and symptoms characterized in TMD. They found
that 79% reported headaches.
The head researcher in the department of clinical
research at Royal Newcastle Hospital in Australia
has described headache as a vast field comprised
many different varieties of headaches and headache
classifications.10 Despite the fact that varying head-
ache classifications exist, headaches appear to have
a common anatomic and physiologic basis, where
they are mediated by the trigeminocervical nucleus
and are initiated by noxious stimulation of the end-
ings of the nerves that synapse on this nucleus.10
Moreover, it has been reported that afferent pain
from the masticatory muscles affects a CNS sym-
pathetic response, leading to increased blood flow,
Correspondence to: Ben Sutter, TMD Headache Oregon, 1045
Willagillespie Rd., Ste. 150, Eugene, OR 97401, USA. Email:
BSutterDMD@aol.com
muscle sensory feedback has been shown to reduce
migraines, as well as tension-type headaches.11 Inter-
estingly, Rasmussen et al.12 found that 83% of
migraine patients had episodes of tension headache,
and 23% of tension headache patients experienced
migraine headaches, as well.
It has been suggested that the three major diseases
dentists treat are caries, periodontal disease, and occlu-
sion,13 where occlusion remains the major untreated dis-
ease in dentistry today.13 There is no doubt that occlusion
is one of the most passionately debated topics in dental
medicine, while being one of the most poorly understood
disciplines. It is this authors opinion that clinicians likely
avoid addressing the occlusion because the profession is
lacking in consensus on the topic.
Within this case report article, it is not this
authors intent to argue the correctness of one
school of occlusal thought over others. Instead, the
purpose is to describe a case study where the inci-
dence and severity of headaches was correlated to
an occlusal force imbalance. It is important to note
that a 50-mm elevated occlusal interference is
enough to cause a recordable elevation in electro-
myographic (EMG) activity, which indicates that
the involved muscles are working to avoid or com-
pensate for the interference.14 Fifty micrometers is
half the thickness of a human hair. It cannot be

W. S. Maney & Son Ltd 2015

DOI 10.1179/2151090315Y.0000000006 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0 1
Sutter Incidence of headaches
overstated how sensitive the proprioception of the
stomatognathic system is.
The idea that minor occlusal adjustments made to
teeth that enhance the occlusion can cause a
reduction in headaches is not new.1518 In this pre-
sented case, coronoplasty was used to alleviate exist-
ing interferences in the patients occlusion, with the
hope of relieving the patients chronic headache con-
dition. The T-Scan Computerized Occlusal Analysis
system (Tekscan, Inc., S. Boston, MA, USA) was
used to confirm the presence of premature contacts
and to assess any existing pre-treatment occlusal
force imbalance. The T-Scan system is a diagnostic
computer-assisted, digital occlusal force, and timing
analyzer. The patient occludes into a thin, pressure
sensitive sensor, which records 256 levels of occlusal
in force fractional time increments, and then displays
the recorded data in movie form on a computer
screen for analysis. The data are used to guide the
clinician in making precise and targeted occlusal
force and timing abnormality corrections.19
What is unique about this specific presented case is
that once the occlusion was stabilized, the patients
headaches lessened from the initial computer-guided
occlusal therapy, because her occlusal balance had
been significantly improved. However, shortly after
the successful occlusal treatment, the patient sustained
a facial trauma that changed the force distribution of
her occlusion, inducing her headaches to return.
In the patients words, the recurrent headaches felt
as bad as they ever were. Following the trauma,
the patients muscles were rehabilitated, after which
the occlusion returned to a balance state that, once
again, alleviated the patients headaches.
Clinical Case
The presented patient was a 55-year-old female, with a
history of experiencing daily temporal headaches for
the past several years. During a routine prophylaxis,
she reported that her headaches began about 2 hours
after arousal from sleep. She stated that she would
often take two to three ibuprofen tablets a few times
throughout the day, to attempt to quell the headache.
She reported that she never woke up from sleep with
a headache, which suggested that nocturnal clenching
was not a major contributor to her symptoms. But
the patient did report having a high-stress job,
which she thought did contribute to her headaches.
The treating practitioner discussed potential thera-
peutic procedures, including orthodontics, corono-
plasty if interferences were present, wearing a
neuromuscular orthotic, and no treatment at all.
Risks and benefits of each treatment option were
2 CRANIOt: The Journal of Craniomandibular & Sleep Practice
discussed, such that all of the patients questions
regarding possible treatments were answered. Perfect
bite therapy now known as TruDenta (Ft. Lauderdale,
FL, USA) and neuromuscular occlusal concepts were
also reviewed with the patient, after which she elected
to undergo occlusal therapy with coronoplasty, as
long as the changes made to her occlusion were
minimal.
A diagnostic occlusal T-Scan recording was made
pre-treatment (Fig. 1), which determined that interfer-
ences existed within the patients occlusion. The
T-Scan system can reveal many force and timing
aspects of the occlusion that occlusal marking tape
and articulating ribbon cannot accurately describe.20
Of note was that 24% of her total occlusal force was
concentrated on tooth #14. The left (green) and right
(red) sides of the arch were not balanced, such that at
maximum intercuspated force (99.6%), the left arch-
half demonstrated 57.7% of the occlusal forces, com-
pared to only 42.3% of the forces present on the right
arch-half. Also, the center of force (COF) trajectory
was non-centered anteroposteriorly (Fig. 1). Her ear-
liest contacts occurred on the anterior right teeth,
and then later in the closure sequence, the COF crossed
over to the left arch-half, but remained anterior to the
COF target zone (Fig. 1). Ideally, the COF icon should
finalize within the white oval, which represents where
the optimal total occlusal force summation should be
located for 2832 occluding teeth. Stated another
way, if a patients occlusion is balanced, the sum of
all the occlusal forces measured at maximum force
should be dispersed among all teeth equally, both
anteroposteriorly and mediolaterally. The findings of
this objective occlusal force examination were
explained to the patient, who then elected to undergo
selective occlusal adjustments to establish a more
balanced and harmonious occlusal force relationship.
Occlusion film (AccuFilm II, Parkell, Inc.,
Edgewood, NY, USA), a high-speed handpiece with
copious water spray, and a fine straight diamond
bur were used in conjunction with the T-Scan find-
ings without applying local anesthesia, to relieve
the interferences present on both arch-halves.
All marked contacts that maintained the vertical
dimension of occlusion (VDO) were intentionally
left intact during the coronoplasty. T-Scan data
were re-recorded after every 34 corrective adjust-
ments had been performed, to monitor the occlusal
force changes resultant from the few prior
occlusal adjustments, and to guide subsequent occlu-
sal adjustments required to better balance the arch-
halves. Treatment was suspended following four
recording and adjustment cycles to avoid making
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Figure 1 Pre-treatment occlusal analysis with the T-Scan. The two-dimensional force window (upper pane) shows that the
center of force (COF) trajectory beginning near the anterior right occlusal contacts and transitions later in the closure
sequence, to the left arch-half, as the patient nears maximum intercuspation (MIP). In the force versus time graph (lower
pane), the angled black Total force line indicates that the patient required a long time to close into MIP because she experi-
enced muscular strain when attempting to firmly close her teeth together. Through occlusal adjustments, this line becomes
vertical in subsequent post adjustment T-Scan testing.

any drastic changes to the occlusion at the initial right arch-halves were corrected to be near equal
appointment. Figure 2 shows the T-Scan treatment occlusal force distribution with 50.3% force on the
day 1 results obtained immediately following the left and 49.7% on the right. However, the COF
final occlusal adjustments. Notice that the left and remained slightly anterior to the desirable occlusal

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Sutter Incidence of headaches

Figure 2 The T-Scan treatment day 1 results obtained immediately following the performed occlusal adjustments. The left
and right arch-halves were nearly equal (50.3% left 49.7% right). But the center of force (COF) icon remained anterior to the
white target zone.

adjustment endpoint, where the COF icon finishes
within the white target zone.
The patient returned 1 week later for a second set of
computer-guided occlusal adjustments. The patient
stated she experienced no headaches since her last visit
and was very pleased with treatment results, thus far.
An initial T-Scan recording illustrated that the left and
right sides were still quite equalized (50.6% left49.4%
right), indicating the first set of adjustments seemed
stable (Fig. 3). Also noteworthy was that the COF
icon was now more posterior than it was 1 week earlier.
A possible explanation for this observation is that the

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 Sutter Incidence of headaches

Figure 3 One-week post op T-Scan data illustrated that the left and right arch-halves were still equalized (50.6% left49.4%
right), indicating that the first set of adjustments seemed stable. Note that the center of force (COF) icon was located more
posterior than 1 week earlier.

removal of interferences reduced the amount of muscu-
lar compensation, which allowed the condyles to sit
higher in position within the glenoid fossa, thereby
allowing for more posterior occlusal contact (and
force). Because of the improved occlusal force profile
and the reported lack of headaches, no adjustments to
the occlusion were made at this 1-week recall
appointment. The patient was to reappoint in a few
weeks to reevaluate the effects of the day 1 adjustments
previously accomplished. As it turned out, there would
be no more adjustments made to the patients occlusion.
Between the patients second and third appoint-
ments, she suffered a fall in the bathroom,
during which the right mandibular angle sustained

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Sutter Incidence of headaches
traumatic impact. Bruising developed around the
orbit of the right eye, the right side of the chin, the
right arm, and the left knee (Fig. 4). The patient
returned for her scheduled reevaluation visit 1 week
following the sustained facial trauma, when she
reported that to this point in time she had not
sought any medical care for her fall. The patient
explained what had happened and was then exam-
ined with palpation of the zygomas, the orbits, and
temporomandibular joints. No tenderness was
reported during this exam other than in the areas
of existing ecchymosis, and no fractures were
found. It was possible that during the right-sided
facial trauma, the mandible was forcibly directed to
the left, thereby compressing tissue in the left tempor-
omandibular joint, resulting in muscle splinting and
capsular edema. However, no tenderness to palpa-
tion was reported, except where ecchymosis was
apparent.
It was noteworthy that in all the T-Scan record-
ings made prior to the sustained mandibular
trauma, occlusal contact initiated in the right
anterior teeth, and when more teeth came together
subsequently in time, the COF moved left poster-
iorly to cross the T-Scan midline. However, within
the 1 week post-trauma T-Scan recording (Fig. 5),
occlusal contact still was initiated on the anterior
Figure 4 The patient fell, injuring the right mandibular
angle. Bruising developed around the right eye, chin, arm,
and the left knee. This photo shows some of the bruising.
6 CRANIOt: The Journal of Craniomandibular & Sleep Practice
right teeth, but was closer to midline, and as the clo-
sure advanced further into maximum intercuspation
(MIP), the COF did not cross the midline, and ter-
minated more posteriorly than in any of the pre-
vious scans. Additionally, the patients occlusal
balance was significantly different post-trauma,
with 62% of her occlusal force located on the right
arch-half, with the remaining 38% present in the
left arch-half.
The patient expressed concern over the return of
daily headaches that were now accompanied by
episodes of vertigo. She questioned whether it
would be beneficial to further optimize her occlu-
sion with further T-Scan-guided occlusal adjust-
ments. However, with mutual agreement, it was
decided that she would be given a week of healing
and then commence a course of in-office, physical
therapy.
The patient returned in 1 week for the physical
therapy, which included:
1. Ultrasound therapy of the masseter, trapezius, and
sternocleidomastoid muscles (Sonicator, Model
ME 740, Mettler Electronics Corp., Anaheim, CA,
USA).
2. Massage therapy for those same muscle groups.
3. Electrotherapy (Alpha Stim 100 Microcurrent and
Cranial Electrotherapy Stimulator, www.allevia-
health.com) used bilaterally, which focused on the
masseter, trapezius, sternocleidomastoid, and ptery-
goid muscles, as well as the occipital area.
4. Low-level laser therapy of the same muscle groups, and
both temporomandibular joints (LED, Model HDC1,
RevC, www.ColdLaserEquipment.com).
5. Application of the mandibular release maneuver,
which is a mild stretch of the mandible to increase
its range of motion.
Immediately following the physical therapy, a T-Scan
recording was obtained (Fig. 6). The occlusal con-
tacts initiated in the anterior right, but were even
closer to the midline than in Fig. 5, indicating that
the early closure contacts demonstrated improved
bilateral occlusal balance. As contact throughout
the arch increased, approaching MIP, the COF
icon crossed the midline and finished nearly in the
center of the COF target, indicating there was a
high degree of occlusal balance. The right-to-left
arch-half occlusal force distribution was nearly
balanced, as well (53% right47% left).
Two weeks later, the patient returned for
additional physical therapy when she reported that
she had experienced only three headaches during
the previous week. At this appointment, both pre
and post physical therapy T-Scan recordings were
made. The pre-therapy recording revealed the COF
was posterior and to the left of balanced (Fig. 7),
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Figure 5 The 1-week post-trauma T-Scan data. Contact still initiated on the anterior right teeth. The center of force (COF)
icon no longer crossed the midline, and ended posteriorly to its location in all previous scans. Finally, the occlusal balance
was changed from the trauma, as well (62% right38% left).

where the left arch-half demonstrated 53% of the
total force, while the right arch-half demonstrated
47% of the total force. Sixty-four minutes later, a
post physical therapy T-Scan recording revealed
improvement to the overall occlusal balance (50.1%
left49.9% right), where the COF was now balanced
anteroposteriorly and mediolaterally (Fig. 8).
Following the physical therapy, the patient reported
her occlusion felt great. Again, because the occlusion
had been balanced before the facial trauma, it was
decided not to make any further occlusal
adjustments. She was then scheduled for a 2-week

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Sutter Incidence of headaches

Figure 6 T-Scan data following physical therapy. The occlusal contact commenced in the anterior right, closer to the midline
than in Fig. 5. The center of force (COF) icon crossed the midline to finish in the COF target. The right-to-left arch-half occlu-
sal force distribution was 53% right47% left.

follow-up visit to observe if the occlusion would
remain balanced and stable.
Two weeks later, the occlusion was again recorded
with the T-Scan (Fig. 9). The COF appeared balanced
both anteroposteriorly and mediolaterally. The patient
denied experiencing any severe headaches in the
previous 2 weeks, while reporting that her condition
had noticeably improved. No adjustments to the occlu-
sion were made at this time. The patient was to reap-
point in 5 months for reevaluation, but was requested
to return prior to that reevaluation if she detected any
changes in her occlusion or in her headache status.

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 Sutter Incidence of headaches

Figure 7 The pre-physical therapy T-Scan data showing a left posterior the center of force (COF) and a 53% left and a 47%
right.

The patient returned after 5 months for her last
Perfect Occlusion Therapy session, to reevaluate her
occlusal stability, her symptoms, and to assess the
need for further occlusal adjustments. Figure 10 illus-
trates a three successive intercuspation, Multi-bite
recording. The three COF trajectories (one per each
intercuspation) overlaid each other in a tight and
repetitive pathway, indicating that the occlusal pat-
tern was easily reproduced when the patient intercus-
pated. The patient stated she experienced painful
headaches that required medication one to two
times per month. Prior to the T-Scan-guided occlusal
therapy, the patient would use medication two to
three times per day, every day.

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Sutter Incidence of headaches
Figure 8 Post physical therapy T-Scan data showed improved occlusal balance (50.1% left49.9% right), and an anteropos-
teriorly and mediolaterally balanced center of force (COF).
Discussion
In this presented clinical case, a correlation between
the patients reported headaches and an existing
occlusal force imbalance existed. The T-Scan system
improved the clinical visualization of how the
patients teeth engaged, and how sustained facial
trauma affected the patients muscles, which
10 CRANIOt: The Journal of Craniomandibular & Sleep Practice
ultimately affected the occlusal force distribution
and the occlusal contact pattern. Additionally, it
would have been beneficial to include simultaneous
EMG recordings21 and temporomandibular joint
sonography to compare with the T-Scan results.
By utilizing the T-Scan before and after physical
therapy, it was possible to observe how the
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Figure 9 Two weeks post physical therapy T-Scan data showed the center of force (COF) still balanced anteroposteriorly
and mediolaterally. The patient denied experiencing any severe headaches in the previous 2 weeks, such that no occlusal
adjustments were made.

physical therapy positively altered the occlusal
force distribution that was worsened from the sus-
tained facial trauma. In this way, the T-Scan con-
firmed that the occlusal force distribution could
change, resultant from muscular rehabilitation.
This was evident not only on the same day of
physical therapy but also over the 5-month
period of observation. The Medical Faculty in
the Department of the University Hospital of
Eberhard Karl University concluded that the
T-Scan is a measuring technique superior to the
usual methods.22

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Sutter Incidence of headaches

Figure 10 A three-intercuspation T-Scan multi-bite recording. The center of force (COF) trajectories overlay one another in a
repetitive pathway, indicating that the occlusal contact pattern was reproducible by the patient after 5 months.

Conclusion between TMD and headaches is well established, as a

As a single-patient case report, with a sample size of
one, the repeatability of the rendered treatment
cannot be ethically extrapolated to larger populations
of headache sufferers. But, headaches have a high
prevalence among TMD sufferers, and the correlation
growing body of literature correlates tension head-
aches to malocclusion. It is noteworthy that headaches
have been considered one of the most common types of
pain, and one of the most frequent causes of patient
presentation to physicians offices and clinics.

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Traditionally, dentists are trained to examine every
single tooth as its own entity. However, clinicians must
also ensure that all the teeth function as one unit, in
harmony with the temporomandibular joints, the mas-
ticatory muscles, and innervating nerves. It is this
authors opinion that this has been somewhat neg-
lected in the traditional dental school education.
As technology advances, dental medicine has a
responsibility to look at the occlusion more comprehen-
sively, with technology that can objectively measure
occlusal force and timing, rather than relying solely on
the very inaccurate method of Subjective Interpret-
ation.23 The T-Scan technology has afforded dental
medicine the ability to assess the occlusion measurably,
in a way that had not been possible prior to its avail-
ability. It is this authors opinion that a more complete
evaluation of the stomatognathic system should include
a measured occlusal force balance assessment.
Disclaimer Statements
Contributors
Funding
Conflicts of interest
I am not a representative of any postgraduate study
program or equipment manufacturer. Nor am I a
paid consultant for either.
Ethics approval
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