Parafunctional Analysis & Diagnostic~Restorative Application

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Posted on By michael melkers In Occlusion

I have been wanting to share some of my practical 'research'~clinical retrospective and its application on XP.

This is the work that my wife, Dr. Jeanine McDonald and I did from about 2002-2012, and how we applied it to diagnostic and clinical dentistry.

Over the course of about 10 years, Jeanine and I colored orthotics/appliances/nigtguards and analyzed the patterns that were created by noctural bruxing, as well as any changes.

Long story short-the patterns never changed. Pre-ortho, post-ortho, pre-restorative, post-restorative, pre-equilibration, post equilibration...

I broke the patterns down into three groups. Of the 300+ cases we analyzed, here are the breakdowns that we saw.

Parafunctional analysis statistical breakdown
Laterotrusive-a combination of protrusive and lateral movements.

Pure protrusive. There was also a group that had wear but the type of pattern could not be discerned or agreed upon
Just to be clear, the devices we analyzed were not limited to NTI's but inlcuded NTI's, Tanners, Universals, Michigans, anterior only, dual arch~DAASA designs...

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At delivery, the patient was intsructed to move their jaw to the sides and as far back as they could and the ranges of voluntary motion were measured.

At 10 days to 2 weeks-in this case 17, the patient returned and the parafunctional ranges were noted and measured. The parafunctional ranges were visible as the black marker had been worn away by nocturnal bruxing.

The patient was also instructed to go through the voluntary ranges with red film in place.

The protocol gives a metric to analyze if the patient can comfortably move at least as far as their parafunctional ranges. This is representative of the 'physical therapy' aspect of orthotic therapy.

This is especially significant in analyzing and comparing the voluntary vs parafunctional ranges of seating as well as excursive movements. If the patient seats of moves parafunctionally beyond what we can observe and record, our restorative design and materials can be at great risk, without us even being aware.

At delivery
17 post delivery


For pre-restorative application, the PA (parafunctional analysis) can provide a metric if the patient can voluntarily seat and be recorded/restored at teh most seated position (sometimes referred to as "CR").

An issue with relying on if 'the patient is comfortable' is that it is subjective. There may be extended patrafunctional ranges which occur at night which exceed what we can observe during the day. The differences between teh apex of teh chevrons tell us that additional time and 'physical orthotc therapy' is required.

Parafunctional wear vs voluntary movement (red)
Voluntary ranges are not equal or coincident to parafunctional ranges


In application, if we restore at the apex of the voluntary position and the patient is still parafunctioning to the apex of the green chevron, they can 'get behind' the dentistry and apply all of the load to the 7's or even continue to seat and develope an anterior open bite.

**Special thank you to Dr. Frank Spear for allowing me to use his skull graphics

Progression of seating
Progression of seating


I think that I have everything cleaned up! Thank you for letting me share Dr. Salama!


This is a critical process in occlusal evaluation. Great post. Regards Maurice


Thank you Maurice!


Thank you for sharing! How did you apply this research to the restorative stage? Gregory


Hey Greg-I am glad you found it interesting.

I find it invaluable in extensive restorative cases. I don't want to get into a CR discussion but I would like to find the most seated point in parafunction (the apex of the green chevron) and also the parafunctional ranges in excursions-the lateral extension of the green lines.

When you look at the red like-the voluntary ranges, you can see that they don't match. These sometimes do not match even when the patient feels fine. They may even repeatably close to the apex of the red chevron.

The issue is that when the parafunctional seating or parafunctional range exceed the patient voluntary movements, they may get 'behind' the dentistry we design..and just parafunction onto the 2nd molars.

If they parafunctional in excursions beyond what they cans how us chairside, then we are not able to evaluate and adjust our new provisionals or final restorations.

I hope I explained that OK...the subject is a lecture or webinar unto itself...or you are so close we could meet and discuss it over a scotch!


I agree with the analysis. John Kois always said if it is "brain" mediated occlusion we can always reduce the risk but do not eliminate.
Do you have any cases to share? And BTW always ready for the scotch!!!Gregory


Greg-all occlusion~occluding is brain mediated. The brain tells muscles to move.

I have a nice Japanese collection-come on up and visit!


Hi Michael & Greg, interesting post. I'm not sure whether I have got it right and I have few questions due to confusion understanding the concepts. Please help me clear my confusion. 1) with bimanual manipulation technique as described by Dawson, CR position can be found and with the help of custom incisal guide table, restorations can be designed. However, in cases where jaw is tight and there is doubt about bimanual manipulation or simply not able to find consistent stable CR postion, we give Nti, anterior appliance or Daasa to release lateral pterygoid and the condyle keeps seating in anterior superior position which in turn can cause contact in 2nd molar or open bite..these appliances also help us to locate the boundaries or the extent of parafunctional movements. My question is how you incorporate those parafunctional jaw movements (that are beyond voluntary movements or even CR position represented by the apex of those lines on your appliances) occuring at night time into your restoration? 2) I'm imagining that while patient is asleep at night, can mandible relax and fall backwards and go to the retruded position where they contact 2nd molar or it can go only to CR position (and not in retruded position) to contact 2nd molar? My imagination is that it can contact 2nd molar in both cr or retruded in your drawings, Does the apex of parafunctional movements represent retruded and not Cr position? or could it be that the pt is still in the process of release of lat.pterygoid and the condyle is further seating? 3) Can patient go beyond Cr position i.e. into the retruded position and contact 2nd molar into that retruded position during parafunction? and if the answer is yes then how do we build the restoration? at CR position and or retruded position. If it is done in CR position, how do you design restoration that can accomodate for retruded position while in parafunction at night time? 4) physical orthotic appliances are meant for release of lat pterygoid and seat condyle in cr position and can also be used to trace the extent of parafunctional movements. Are there any other indications or use ? Michael, thank you so much for sharing.


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