Clinical Science

Jayne

A Deprogrammer for Occlusal Analysis

and Simplified Accurate Case Mounting

byDon Jayne, D.D.S.

Dr. Jayne graduated from the University of Abstract

Washington School of Dentistry (UWSD)
Centric relation (CR) has been well described in the literature
in 1975. After completing a residency at Il-
(a partial list of appliances and techniques include the Lucia Jig,
linois Masonic Medical Center in Chicago,
he returned to teach at UWSD. While there the leaf gauge, and the bilateral manipulation technique1-13); and,
he developed and directed the Harborview although easy to understand, it often is elusive to achieve clini-
Medical Center Dental and Oral Maxillofa- cally. Anyone who has attempted to mount cases in CR knows that
cial Clinic. Dr Jayne lectures on cosmetic some patients can be extremely difficult to manage for accurate
dentistry, occlusion, and various aspects of bite relationships. The Kois Deprogrammer has been found to be
restorative dentistry. He maintains hands- an effective device for achieving these bite registrations. It offers
on cosmetic and restorative study clubs and a CR mounting technique and protocol that help the restorative
is the director the AACD Summit Affiliate dentist achieve predictability and accuracy. It has several other uses
Hands-On Esthetic Continuum. Dr. Jayne as well and is an invaluable tool in diagnosing the three most com-
is a clinical instructor at the Kois Center in
mon types of abnormal occlusal attrition: occlusal dysfunctional,
Seattle, Washington, where he maintains a
parafunction (e.g., bruxism), and a constricted path of closure 
cosmetic/restorative practice.
(Figs 1-3).

The KD is not a proprietary appliance, and it can be made by

any independent laboratory.

Kois Deprogrammer
The Kois Deprogrammer (KD) is a palatal-coverage maxil-
lary acrylic device with a flat plane lingual to the anterior teeth.
It separates the dental arches and provides a single lower-central
incisor contact against the anterior bite plane. The KD can also be
described as a Hawley appliance14 with a modified anterior bite
plane. It is important to note that the KD is not a proprietary appli-
ance, and it can be made by any independent laboratory.

 
96 The Journal of Cosmetic Dentistry • Winter 2006 Volume 21 • Number 4
Clinical Science Jayne

Figure 1: The Kois protocol recommends this design Figure 2: This design variation for the KD is useful
with a labial arch wire. for patients with high esthetic demands.

Centirc Relation • Constricted path of closure one week). If the patient is not com-
Centric relation is described as (CPC): Attrition occurs during pletely deprogrammed by that time,
the maxillomandibular relationship closure into MIP when anterior it may be necessary for the patient to
in which the condyles articulate interferences create a distal wear the deprogrammer for up to 24
with the thinnest avascular portion thrust that moves the condyles hours per day (except when eating).
of their respective disks with the distal to CR (Fig 4). In this case the duration should be
complex in the anterior-superior • Occlusal dysfunction: Occlusal limited, preferably no longer than
position against the shapes of the attrition as a result of excessive one week. This is to prevent poten-
articular eminences.12 This position grinding triggered by interfer- tial supraeruption of the posterior
is independent of tooth contact and ences on the posterior teeth   teeth or intrusion of the contacting
is clinically discernible when the (Fig 5). incisor.
mandible is directed superiorly and • Parafunction (true bruxism): Many types of appliances and
anteriorly. It is restricted to a pure- Occlusal wear as a result of techniques can be used to attain
ly rotational movement about the excessive grinding triggered by CR.1,2,7-9,15 The KD has a number of
transverse horizontal axis. the brain. It has no functional features and benefits that make it
purpose. an ideal protocol for obtaining CR 
Applications of the KD or managing a number of occlusal
Numerous clinical applications issues:
for the KD have been determined. It It is worn until the necessary
• It allows for the patient to
can be used for simplifying difficult muscle deprogramming is
deprogram over time. It has
bite registrations and for accurate accomplished and can be worn for
days or weeks if necessary. been has shown that in patients
mounting of diagnostic casts, for pa-
with a centric prematurity
tients that are difficult to manipulate
introduced for a short period of
into CR, and for facilitating occlusal
Features and Benefits of the KD time, a percentage of them may
adjustments (during which time it
take days or weeks to lose the
is worn). The KD can be used as a The KD appliance is designed
muscular discoordination in the
diagnostic tool to determine if the such that it can be worn for ex-
muscles of mastication once the
mandible needs to move in the an- tended periods of time, as long as it
prematurity is removed.16 This
terior or posterior direction to reach does not exceed 20 hours per day. It
explains why some patients will
CR from maximal intercuspal posi- is worn until the necessary muscle
not deprogram instantly or in
tion (MIP). The device is also used deprogramming is accomplished
a few hours. In these cases, an
to differentiate among three types of and can be worn for days or weeks
accurate record cannot be taken
abnormal occlusal attrition: if necessary (the usual course is for

 
Volume 21 • Number 4 Winter 2006 • The Journal of Cosmetic Dentistry 97
Clinical Science Jayne

Figure 3: The appliance is stabilized by the palate and Figure 4: Anterior interferences cause the mandible to
arch wire or clasps. shift distal to CR.

until they have been completely maintained during the occlusal tooth contact, the feedback and the
deprogrammed. adjustment (Fig 7). influence of the dentition on the
• The jaw is not manipulated into • It can be worn at a minimally condylar position is lost. Tooth-de-
CR, but is determined by the opened VDO of approximately flecting inclines can trigger discoor-
patient and is reproducible. This 1 mm in the molar region. This dination of the masticatory muscles.
is a key criterion to determine closed position is often more Until these muscles relax and func-
if the patient is deprogrammed. comfortable than appliances tion in a coordinated manner, the
The patient must be able to that require a much greater patient may be incapable of achiev-
close into the same position VDO. This also makes the appli- ing a CR position. The KD breaks
every time, passively, without ance more esthetic if needed for this cycle by discluding the teeth
any guidance or external force. daytime use. and allows the muscles to return to
normal function. The KD protocol
• The patient can be observed • It is self-adjusting. There is
also verifies that the muscles of mas-
when closing into a reproduc- only one incisor tooth contact
tication are deprogrammed. This en-
ible CR mark. This position can against the appliance. As the
sures that the condyles are allowed
again be verified when the bite muscles relax, the condyles are
to “move” to the CR position, being
registration is taken. The patient free to move with no obstacles
unaffected by uncoordinated mus-
should make the same mark on to prevent them from achieving
cles, tooth interferences, or operator
the appliance during the bite an equilibrium position in CR.
error.
registration as was made during This saves multiple adjustment
the initial recording. appointments.
• The bite registration is taken Discussion
with the appliance in place. The “classic” patient for an ante-
The CPC patient often can fool
This allows great control of the the clinician; he or she may be rior appliance is one who is experi-
vertical dimension of occlusion asymptomatic, easy to manipulate, encing obvious muscle disharmony
(VDO) during bite registration and give reproducible mountings. and is very “tight” or difficult to ma-
(Fig 6). nipulate. There are other cases, how-
• It is used to facilitate an oc- ever, that appear easy to manipulate
clusal adjustment once the How Does it Work? into CR and yet require the extended
deprogramming is complete. deprogramming time in order to
Proprioceptors in the periodonti-
The same appliance can be achieve the CR position. The ques-
um provide feedback that programs
used. Use of the KD ensures tion is, “Which patients are they?”
the muscles to close in MIP. With-
that the deprogramming will be This can be difficult to answer.
out reinforcement through repeated

 
98 The Journal of Cosmetic Dentistry • Winter 2006 Volume 21 • Number 4
Clinical Science Jayne

Figure 5: Posterior interferences can precipitate Figure 6: The initial point of contact can easily be
grinding as well as avoidance patterns. This can lead visualized during evaluation of deprogramming and
to significant attrition of the anterior teeth. for the bite registration.

The CPC patient often can fool toms. These patients are forced to groups will grind on the KD, as the
the clinician; he or she may be  continually adapt to this position. If etiology of the grinding has been
asymptomatic, easy to manipulate, their ability to adapt is diminished, removed (i.e., once the patient has
and give reproducible mountings. possibly from stress or trauma, they been deprogrammed). If the patient
Testing these patients with a depro- run a much greater risk for becom- does develop a wear facet on the
grammer will verify the achievement ing symptomatic. These patients anterior discluding device, by pro-
of CR. function on the lingual surface of cess of elimination, the attrition is
Patients that potentially fall into the maxillary incisors during masti- caused by the parafunction habit 
the CPC category include those with cation. They may develop significant (Figs 9 & 10). (Note: There is a fourth
a deep overbite, a steep interincisal wear on both the lingual surfaces of category of patients who have a neu-
angle, those that have been over- the maxillary incisors and on the la- rological disorder. Fortunately, they
closed during occlusal adjustment, bial surfaces of the mandibular inci- are relatively few in number. They
post-orthodontic patients, patients sors. The CPC must be corrected in will usually present with an under-
with overcontoured anterior res- order to alleviate this risk. lying medical diagnosis and can be
torations, and patients who have Patients functioning anterior to very difficult to manage.)
been previously restored in CR. It CR are at a lower risk for becoming Making this distinction is impor-
has been the author’s experience symptomatic as there is more “give” tant because each diagnosis requires
that these CPC patients (those with to the system. These patients, how- a different type of treatment. The
condyles positioned posterior to CR ever, may develop significant attri- CPC patient can be the most diffi-
in MIP) comprise a significant per- tion as a result of grinding caused cult to manage. Correction of this
centage of the population. Many of by posterior interferences (occlusal problem will require that the jaw
these patients were easy to manipu- dysfunction). This excessive attrition come forward to CR. This means
late using bilateral manipulation can be stopped by correcting the oc- the maxillary and mandibular ante-
or anterior discluding devices, gave clusal interferences. This will lower rior teeth must be moved out of the
reproducible mountings, and then the restorative risk as well. way. This can be done by moving
shifted significantly forward during The KD is useful for diagnosing the maxillary anterior teeth to the
deprogramming with the KD. between three types of abnormal labial; moving the mandibular ante-
Accurate mounting allows for an attrition (CPC, dysfunction, and rior teeth to the lingual; opening the
accurate diagnosis. This is important parafunction [bruxism]). CPC at- bite; shortening the anterior teeth;
as CPC patients are at significant risk trition occurs during closure into reducing on the labial of the lower
for damaging their anterior teeth MIP, and mastication. Dysfunction- anterior teeth; or, in some cases,
and restorations (Fig 8). They may al attrition occurs throughout the moving the jaw.
also develop muscle or joint symp- entire day. Neither of these patient

 
Volume 21 • Number 4 Winter 2006 • The Journal of Cosmetic Dentistry 99
Clinical Science Jayne

Figure 7: Facial view demonstrates how the patient Figure 8: CPC patients can cause significant
can be significantly closed during the bite registration. attrition on anterior teeth. These patients often cause
significant damage to anterior restorations.

Figure 9: A satin finish aids in the rapid diagnosis of Figure 10: The KD is an anterior discluding appliance
wear facets on the device. and can be used to help manage accurate bite
relationships.

The patient with dysfunctional terior platform should be adjusted opposing teeth when the patient re-
attrition is managed by removing horizontal to the occlusal plane. laxes into CR. Approximately 1 mm
the interferences. This may be very The single mandibular tooth contact of clearance should remain, and the
simple to treat, often with only an should be as close to the midline clinician should be sure to check. If
occlusal adjustment. It can also, as possible. There should be only the platform is too thick, some pa-
however, be more complex. The one point of contact. The platform tients can develop vague muscular
bruxism patient is managed with a should not cause the mandible to pain. Do not make the platform any
biteguard, as the bruxism cannot be deviate laterally (Fig 11). It should thicker than is necessary (Table 1).6
stopped by occlusal therapy.17 The allow the mandible to move freely The patient should not wear it dur-
occlusion can also be modified to in an anterior, posterior, and lateral ing meals or wear it so much that it
redistribute the occlusal forces. direction. The surface should be flat causes quality-of-life issues. The pa-
and should extend far enough an- tient should be cautioned to discon-
Deprogrammer Protocol teriorly and posteriorly that the pa- tinue use and to contact the practice
The deprogrammer is inserted tient cannot lose contact with either if he or she experiences increased
on the maxillary arch similar to a end. The platform should be thick pain, which may indicate an intra-
maxillary Hawley appliance. The an- enough to prevent contact with the capsular problem.6

 
100 The Journal of Cosmetic Dentistry • Winter 2006 Volume 21 • Number 4
Clinical Science Jayne

Figure 11: The platform should facilitate a passive Figure 12: The pattern seen here is typical of a patient
anterior-posterior slide without deviation. This is who is not deprogrammed. This patient will need to
evaluated with articulating paper. wear the appliance for a longer period of time during
the day.

Figure: 13: This patient has been successfully

deprogrammed and is ready for bite records.

When Is the Patient (Figs 12 & 13). Make sure that the in the joint indicates that the patient
Deprogrammed? patient is not hitting any teeth as he cannot accept loading.
The patient is deprogrammed or she moves toward CR.
when he or she reproduces the same Summary
Contraindications
single spot on the platform with-
Contraindications include any The KD offers an easy CR mount-
out guidance or support. The spot
patients with joints that will not ac- ing technique and protocol that help
needs to be absolutely flat with no
cept loading. A patient who cannot the restorative dentist achieve pre-
slide whatsoever and the spot must
accept loading indicates that there dictability and accuracy in an area
be repeatable. The patient should be 
may be a capsular problem. The KD that can be very difficult. Depro-
asymptomatic and will know when
contacts only in the incisal region gramming the patient can take
he or she continues to contact the
and, as with all anterior splints, time and for that reason, it may be
same spot on a tooth immediately
places most of the bite force on the extremely difficult to obtain a true
after removing the KD. Patients
temporomandibular joint. A simple CR position without deprogram-
marking in more than one place are
test to diagnose this is to place cot- ming certain patients. Patients that
not deprogrammed. They will then
ton rolls between the anterior teeth require deprogramming can be dif-
need to wear the deprogrammer
and have the patient squeeze. Pain ficult to diagnose in advance.
more hours per day, or for more days 

 
Volume 21 • Number 4 Winter 2006 • The Journal of Cosmetic Dentistry 101
Clinical Science Jayne

Fabrication Protocol for the Kois Deprogrammer6

• Make stone, full-arch casts of the maxillary and mandibular arches.
• These casts should be mounted in a maximum intercuspal position.
• Bite records and facebows are not necessary.
• Fabricate labial bows to extend from the most distal tooth on each side of the arch.
There should not be any wires to interfere with the occlusal surface.
• Complete full-palatal coverage with acrylic to allow for complete intercuspation of all
teeth initially.
• Add a small anterior stop opposing the lower central incisors that slightly  
discludes all teeth.
The laboratory should note that the anterior platform (i.e., bite discluder) should be
added after the palatal-coverage portion has been fabricated. This will save extensive acrylic
grinding later if completing the occlusal adjustment with the appliance.

Table 1

The KD has other uses that are References practice. Int J Periodont Rest Dent. 5(6):52-
76, 1985.
very helpful to the restorative den- 1. Azarbal M. Comparison of myo-moni-
tor centric position to centric relation 11. Posselt U. Terminal hinge movement of the
tist. Diagnosis of the accurate con-
and centric occlusion. J Prosthet Dent mandible. 1957. J Prosthet Dent 86(1)2-9,
dylar position is important in de- 38(3):331-337, 1977. 2001.
veloping a proper treatment plan. 2. Dawson PE. Evaluation, Diagnosis, and Treat- 12. Editorial Council of the Journal of Prosthet-
Accurate diagnosis is critical espe- ment of Occlusal Problems (2nd ed., pp. ic Dentistry. The Glossary of Prosthodon-
cially for CPC patients. If a patient 183-200). St. Louis, MO: Mosby; 1989. tic terms GPT-7. St. Louis, MO: Mosby;
1999.
needs to come forward to develop 3. Dawson PE. Optimum TMJ condyle posi-
tion in clinical practice. Int J Periodont Rest 13. Weinberg LA. Optimum temporoman-
a stable jaw position, this can have dibular joint condyle position in clinical
Dent 5(3):10-31, 1985.
a dramatic effect on the treatment practice. Int J Periodont Rest Dent 5(1):10-
4. Dawson PE. A classification system for oc-
plan. The KD allows diagnosis of 27, 1985.
clusions that relate maximal intercuspa-
the three types of abnormal occlu- tion to the position and condition of the 14. Proffit WR, Fields Jr. HW. Contemporary Or-
temporomandibular joints. J Prosthet Dent thodontics (3rd ed., pp. 604,605). St. Louis,
sal attritions (each having a different MO: Mosby; 2000.
75(1):60-66, 1996.
treatment protocol). Finally, the KD 15. Fenlon MR, Woelfel JB. Condylar position
5. Gelb H. The optimum temporomandibular
simplifies occlusal adjustments as joint condyle position in clinical practice. recorded using leaf gauges and specific
it can be worn during the occlusal J Periodont Rest Dent 5(4):34-61, 1985. closure forces. Int J Prosthodont 6(4):402-
408, 1993.
adjustment to maintain deprogram- 6. Kois J. Occlusion: Complex restorative
management. Course 8 Manual. Seattle, 16. Sheikholeslam A, Riise C. Influence of ex-
ming throughout the adjustment.
WA; 2004. perimental interfering occlusal contacts on
The many features and benefits of the activity of the anterior temporal and
7. Long JH. Locating centric relation with a
the KD make it a powerful tool to leaf gauge. J Prosthet Dent 29(6):608-610,
masseter muscles during submaximal and
increase predictability of diagnosis maximal bite in the intercuspal position. J
1973.
Oral Rehabil 10(3):207-214, 1983.
and treatment. 8. Lucia VO. A technique for recording cen-
17. Simon RL, Nicholls JI. Variability of pas-
tric relation. J Prosthet Dent 14:492-505,
sively recorded centric relation. J Prosthet
Acknowledgment 1964.
Dent 44(1):21-26, 1980.
The author thanks Dr. John Kois for 9. McNeil C. Science and Practice of Occlusion.
Hanover Park, IL: Quintessence Publish- ______________________
allowing him to adapt portions of his
ing Co; 1997. v
manual.
10. McNeill C. The optimum temporoman-
dibular joint condyle position in clinical

 
102 The Journal of Cosmetic Dentistry • Winter 2006 Volume 21 • Number 4