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Vertical dimension and freeway space. A kinesiographic study

Article  in  The Angle Orthodontist · April 1987

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 Vertical Dimension and
Freeway Space
Peter A. Konchak
A Kinesiographic Study
Norman R. Thomas
Dennis T. Lanigan
Richard Devon
A statistical correlation is found between the S-N/mandibular
plane angle and clinical freeway space, but there was no correla-
tion after TENS stimulation. The S-N/MP angle did rrot prove to
be a reliable predictor of freeway space.
KEY WORDS: ' FRrElvey spAcE . KrNesrocnapr-l . Resr posrrroN .

reatment of patients with extreme vertical discrepancies poses severe difli-

I
I culties for the orthodontist. These cases include patients with short faces
and low sella-nasion/mandibular plane (S-N/MP) angles ar one exrreme of the
spectrum, and with long faces and high S-N/MP angles ar the orher. Cephalo-
metric analyses of variations in facial height have not proven adequate ro fully
assess these cases. It is still largely a matter of conjecture ro prognosricate stability
in cases of overbite and openbite corrections in these types of parients.
The vertical position of the maxillary and mandibular dentition is essentially
an equilibrium between occlusal forces and the eruptive forces of the teeth. This
balance may be changed by orthodontics alone, or in combination with orthog-
nathic surgery. A myriad of factors and variables involving bone, teeth, and soft
tissues are involved in changing this balance.
In order to describe the combinations of these variables, orthodontists have
traditionally used a descriptive approach based on a clinical examination and
cephalometric and/or dental cast analyses. As these are static rather than dynamic,
the physiology of the stomatognathic and neuromuscular sysrems can be evalu-
ated only through direct clinical examination.

Peter Konchak is Associate Professor in the Division of Orthodontics at the Universitv o1

Saskatchewan College of Dentistry in_saskatoon. He holds a D.D.S. degree from the Univeisity
of Toronto, Diploma in Paedodontics from the University of Toronto, and Diploma in Orthodon-
tics from the Univer.sity of Alberta.
Norman Thomas is Professor in the Division of Oral Physiology, Faculty of Dentistry, at the
University of Alberta at Edmonton. He holds B.Sc., B.D.S., and Ph.D. degrees, and a C-ertificate
in Oral Pathology.
Dennis Lanigan is Associate Professor in the Department of
Author Address: Diagnostic and Surgical Sciences at the Univeriity of Sas-
Dr. peter A. Konchak in Saskatoon He holds D.M.D. ana V.O.
\atchewan a Certificate in oral Surgerv
of D"nti;;;'
college
Un i ve rs it!
o r sasrca t;li.ll
5iT T
::fl::i':::
i,il;'"1 ;i#:i:il' Ji3'ff,:l,i 3t';lT,",il :i
Saskatoon, Saskatchewan Saskatchei,'an in "h
Saskatoon. He holds B.Sc. and ph.D.
S7N OWO CANADA degrees,

@The Angle Orthodontist April, 1 987 I +5

 Konchak et al.
This investigation was undertaken to
evaluate certain morphometric and phys-
iologic properties of the craniofacial com'
plex and their possible correlation. The
classical orthodontic diagnostic approach
to diagnosis is through the description of
what are essentially static relationships
among the teeth, soft tissues, jaws, and
cranial base. While the morphology of
the craniodentofacial complex does have
functional ramifications (ScHuov 1964,
Sessouxr 1969, aNo PaoI-INI l97o), the
physiologic parameters interacting with
the morphology are almost entirely
unknown. The orthodontist is, there-
fore, in the unenviable position of hav-
ing to produce a diagnosis, treatment
plan, and prognosis without benefit of
information about physiologic influ-
ences on the morphology.
Identical treatment methods used for
what appear to be anatomically similar
cases often produce different results.
The reasons for this are unknown, but
the explanation may reside in the phys-
iologic di{Ierences between individuals
and, in particular, the neuromuscular
adaptations which coexist with any
given morphological abnormality.
f,l ccrino rrprtinal dimcncinn fn. .rom-
ple, including the freeway space (fwS),
is essentially an adaptive physiologic
parameter (Monl 1978, McNaMARA Er AL.
r978).
Freeway space has been defined as the
neutral rest position of the mandible
which it attains as it is involuntarily sus-
pended by the reciprocal coordination of
the elevator and depressor masticatory
muscles with the upper and lower teeth
separated (Nrswoucrn r934). McNIMARA Er
er-. (1978) state that rest position is influ-
enced by the activity of the fusimotor
system of the elevator muscles through
psychic input and through stimuli from
peripheral receptors such as those Iocated
in the temporomandibular joint, perio-
146 April, '1987 The Angle Ofthodontis9
dontal ligament, gingiva, tongue, and
palate.
Despite the likely importance of the
freeway space, little information relating
vertical dimension ro the freeway space
is available in the orthodonric literarure.
WrnNsn (1956) noted that the reasons for
differences in the freeway space have not
been investigated. Bnnr.rxrnr (1974) felt that
freeway space was ignored in orthodontic
diagnosis and trearment planning. Lruon-
ceno (1953) stated that the size ofthe free-
way space is related to the structure of
the faciai skeleton, especially the form of
the lower face. In his study, freeway space
was found to be negatively correlated
with the anterior lower face height and
positively with the posterior lower face
height.
The basis for an orthodontic assess-
ment of vertical dimension, according to
JnuxnrsoN (1982), is rhe determination of
"true" physiologic rest posirion. This is
best elicited using the mandibular kine-
siograph (MKG) and the myomonitor
(Myotronics Research, 1977). He states
that "a rational prerequisite to orthodon-
tic diagnosis is to decondition the mus-
cles by eliminating proprioceptive input
from the existrng malposirioned occl'.r-
sion." The most rapid eflective means
for accomplishing this deconditioning of
the musculature is through transcutane-
ous neural stimulation (TENS) of the
motor division of the fifth nerve, includ-
ing its proprioceptive fibre content.
Fulrr (1977) and Gooeux auo DrsuEor
(1975) demonstrated that transcutaneous
stimulation produced deconditioning of
musculature by reducing muscle spindle
feedback. The proprioceptive disfacilita-
tion following TENS has been explained
by antidromic block via the fifth cranial
nerve motor fibers (Horrnaeu r9r8, Mac-
LADERv 1955, Hor'l,ua 1959), inhibition by
upper motor neurons on the motor
nucleus of the trigeminal nerve (Tbasoarr

Er AL. r952), and deactivation of the
gamma motor neuron drive to the muscle
spindles (V,lrrro r97r).
The muscle relaxation that results from
TENS-induced proprioceptive disfacilita-
tion of the fifth motor neurons is not a
fatigue phenomenon, as is shown by the
heightened masticatory muscle force fol-
lowing TENS, the elevated maximal
velocity of iaw closure, and the increased
integrated electromyographic activity of
the masticatory musculature during
clenching.
Reduction in the amplitude of the ele-
vator masticatory muscle stretch reflex
(iaw ierk) is also readily evident in post-
TENS treated subjects. The amplitude of
the resting electromyographic activity of
the masticatory musculature is also
reduced following TENS.
The proprioceptive disfacilitation is
sustained as long as the teeth are not
brought into occlusion and TENS is main-
tained (JrNxErsoN eNo RRoxr 1978). Fuyrr
(1977) has found that the proprioceptive
disfacilitation is released at a slightly
longer interval than B0-95msec, a time
that is clearly not indicative of a fatigue
phenomenon.
In the MvornoNrcs (1977) publication,
"adaptive" and "true" rest positions of
the mandible are described, and as a cor-
ollary, "adaptive" and "true" freeway
spaces. Adaptiue freeway space is defined
as the interocclusal space that exists when
the patient is instructed to voluntarily
allow the jaw to relax. The nue Jreeway
space is defined by Jankelson as the iaw
position after transcutaneous electrical
nerve stimulation by the myomonitor.
Wessberg (VEsssrnc nNn ERxrn r98r,
1983, $0rssrrRc Er AL. 1981, r98z) has defined
"clinical" and "physiological" rest posi-
tions of the mandible that appear to cor-
respond to Jankelson's "adaptive" and
"true" rest positions of the mandible.
Rucs .rNu Dneco (198r) studied rest posi-
@The
Freeway Space
tion and jaw muscle activity using EMG
and the kinesiograph and reported that
clinical rest position is accompanied by
muscular activity. Ynnnu auo Brnnv (1969)
conclude that mandibular rest position is
largely governed by an equilibrium of
elastic forces when the subject is fully
relaxed and muscle activity is not funda-
mental to the posture. Groncr nNn BooNr
(t97il, from their study utilizing the
MKG and myomonitor, concluded that
clinical rest position was not coincident
with minimal muscle activity.
Objectiae of Pilot Study
The specific objective of this investiga-
tion is to ascertain whether there is an
association between freeway space, as
recorded by the mandibular kinesiograph
(MKG) before and after stimulation with
a myomonitor, and the vertical dimen-
sion of the face as measured by the sella-
nasion/mandibular plane (S-N/MP) angle
on a lateral cephalograph.
Materials and Methods
- -
n E subiects were selected from
L Jpatients and staffar rhe University
of Alberta. The age range was from 1l
years 3 months to 48 years 2 months.
These subjects had natural dentitions,
and complained of no symptoms sugges-
tive of temporomandibular joint
dysfunction.
Lateral cephalometric radiographs were
obtained for each patient with Frankfort
plane horizontal, and with the mandible
in the centric occlusion position. S-N/
MP angles were measured, and subjects
arranged from low to high S-N/MP
angles in three groups:
Group I <25" N:5
Group II 25-38" N: l5
Group III > 38o I.l: 5
Angle Orthodontist April, '1987 147
Konchak et al.
Subjects were comfortably seated in a
dental chair in a shielded Farady cage,
and the transcutaneous electrical nerve
stimulation instrumentation (myomoni-
tor) and mandibular kinesiograph (MKG)
were applied according to Jankelson's
method (Mvornoutcs 1977, J,rNxrrsoN AND
Reoxe 1978), with the exception that read-
ings were taken with patients seated
rather than standing (Fig. l).
A constant, repetitive sweep on the
kinesiograph oscilloscope was required
before location of either "adaptive" or
"true" rest positions was considered to
have been determined (Fig. 2). The mea-
surement of "adaptive" or clinical rest
position was determined before stimula-
tion with TENS. From clinical rest posi-
rion, subjects were instructed to close into
centric occlusion, and "adaptive" free-
way space was thus determined and
recorded from a polaroid photograph of
the MKG screen.
The subjects were then pulsed preauri-
cularly over the motor division of the
trigeminal nerve with TENS for a mini-
mum of 40 minutes, or until a stable
resting position was obtained. Sublects
were instructed to keep their teeth from
contacting during pulsation and during
the measurement of the postpulsaton rest
position. Vhen this position had been
determined, subjects were then requested
to close into centric occlusion, and "true"
freeway space was determined and
recorded.
Statistical analyses of the measured
parameters we re then undertaken to
determine correlations between S-N/MP
angle and "adaptive" and "true" freeway
spaces.
Results
- -
The subjects were arranged into the three
groups in orcier of increasing S-N/MP
angle and the mean values for "adaptive"
and "true" freewav sDaces calculated
148 April, 1 987 The Angle Orthodontis9
(Thble l). Differences between the pre-
and poststimulation measurements were
seen to both increase and decrease with
respect to the adaptive freeway space
measurement, although the mean differ-
ence for each group was seen to be posi-
tive (Fig. 3).
The overall mean "adaptive" and
"true" freeway spaces for the 25 subjects
in the study was l.8mm and 2.9mm
respectively. An analysis of variance to
compare the adaptive and "true" freeway
spaces of these subjects showed a signifi-
cant increase in freeway space following
transcutaneous electrical nerve stimula-
tion(F11,2r1=1 .625) (.01 <P<.02).
This statistical rest also revealed that
subject variation was significant, indicat-
ing that not all subfects reacted in the
same manner to the electrical stimulation
(Fpa,251:2'64) (.01 < P < .02).
An analysis of variance was also per-
formed to learn whether low (<25') S-
N/MP angle subjects behave diflerently
from medium (25-38') and high (>38")
S-N/MP angle subjects. The results
demonstrate no significant variation
among these groups, although the sample
size of this study may be too small to
detect some statistical differences.
Linear regressions were performed to
determine whether there was any corre-
lation between the S-N/MP angle and
the "adaptive" and "true" freeway
spaces. These demonstrated that there
was a significant negative correlation
between "adaptive" freeway space and
S-N/MP, with 34.590 of the variation in
freeway space being accounted for by the
S-N/MP angle (r:0.587; slope: -3.34
and intercept:37 .49 (Fig. a).
The "true" lreeway space, however,
did not correlate with the S-N/MP angle,
with only l9o of the variation in freeway
space accounted for by total variation in
the S-Ni MP angle (r = 0.1066;
slope: -0.35 and intercept:32.31) (Fig.
5).
 Freeway Space

Flg. I Myomonitor, Kinesiograph, and Sensor array.

Notc maenet attached to mandibular incisor tccth.

@The Angle Orthodontist April, 1987 149

Konchak et al.

Fig.2 Kinesiograph tracings of movements of the mandible vertically,

anteroposteriorly, and laterally on closure from rest position to centric
occlusion.
In this tracing, the mandible closed vertically 2.2mm, anteriorly .5mm,
and to the left 1mm.
Time Basc 1 cm/sec.
V Vertical movement of mandible (1mm/division)
AP - Anteroposterior movements of mandible (1mm/division)
RL - Lateral movements of the mandible (1mm/division)
CO - Ccntric occlusion
RP - Rest position
-

Table I

Freeway Space Measurements

for different
Mandibular Plane Angle Groups
{millimeters t standard deviation}

<25" 5 6t 1.4 4.o !2.) 0.4mm

2 t-l8' t5 4 to.8 2.4 ):2.4 l.0mm
> 18" 5 4 +O.9 3.4tt.3 2.Omm
All E:1.3 ) O+) ) l.ot 1.9
Coeff. of Variation 7t% 2 E",6 r8l%

'150
April, 1987 The Angle OrthodontisP
 Freeway Space

45

40
H
:--
1q

ce-t o--------------f
30
c t::-----------{
z H
a ta
I

20
o "Adaptive" (before)
15 . "True" (alte4
a----=o o No change
10
456
Freeway space

Fig.9 Individual changcs in freeway spacc after stimulation, plotted

against S-N/MP.

t30
z=
I
a

Fig. 4 Poststimulation "adaptive" freeway space vs. S-N/MP.

@The Angle Onhodontisf April, 1987 151

Konchak et al.
t30
z=
I
a
Fig. t Poststimulation
Discussion
- -
The desirability and validity of
freeway space measurements in dentistry
has been widely debated. Srr-vrnr.rnN (r957)
criricizeci principies anci techniques based
on rest position and freeway space as "the
greatest single cause of so much confu-
sion of maxillo-mandibular relations".
Arwooo (rSS6) and OrsrN (rg5l), using
cephalometrics, showed that freeway
space was not an accurate procedure. In
their studies, measurements were made
before and after loss of the dentition, with
dentures in and out of the mouth, at the
same and at diffbrent sittings. Freeway
space measurement varied in the same
patients.
One possible reason for this uncer-
tainty is thar the various clinicians and
researchers are often discussing and eval-
uating two separate entities
- physio-
logic and clinical rest position, without
152 April, 1987 The Angle Onhodontis9
"true" frceway space vs. S-N/MP.
adequately differentiating between the
two. The means for measuring these two
using positions was also inadequate until the
use of the myomonitor and kinesiograph
enabled clinicians to accurately measure
both of these positions of the mandible
(JanxnrsoN aNo Repxn 1978, MvornoNrcs
1977, HeHNeM Er AL. 1977, JeNxu,soN r98o).
It is only recently that researchers have
begun to use this sophisticated technol-
ogy to investigate freeway space.
PErrnsoN rr el. (1983) found a diflerence
in the amount of freeway space between
individuals with diverse craniofacial pat-
terns, with the low Frankfort/mandibular
plane angle group having larger freeway
spaces. rWrsssrnc rr el. (1982) found the
interocclusal distance at physiologic rest
position to be inversely related to the
vertical dentofacial morphology.
In this study, thc "adaptive" or clinical
freeway space was significantly corre-
lated with the sella-nasion/mandibular

plane angle, whereas "true" or physio-
logic freeway space was not. Although
there was an overall mean positive
increase in freeway space of l.lmm after
TENS stimulation, it should be noted that
differences between freeway space before
and after stimulation could be either
positive or negative. If relaxation of the
muscles does occur (JeNxu-soH I98z), it
does not necessarily mean that freeway
space values are larger after stimulation.
Relaxation of the musculature is thus not
necessarily synonymous with an increase
in freeway space, as it could depend upon
whether the elevator or depressor mus-
cles have been relatively more relaxed.
Despite the statistical significance of
the correlation between "adaptive" free-
way space and S-N/MP angle in the pre'
pulsed state, values for freeway space
showed individual variation. The indi-
vidual high or low S-N/MP angle patient
did not always have a small or large free-
way space before or after IENS. This
observation may partially explain the
individual variation in response to treat-
ment changes in the vertical dimension
within high S-N/MP or low S-N/MP
groups. This may have particular applic-
ability to overbite correction by molar
extrusion in the low S*N/MP grouP.
It is difficult to propose a conclusive
explanation for these findings, except that
a variation in clinical freeway space can
be partly explained by a variation in a
patient's vertical dimension as reflected
in the S-N/MP angle. The cephalome-
tric measurements used in these studies,
although useful to describe facial propor-
tions, did not give consistent indications
of the size of the freeway space.
Freeway space is a description, how-
ever limited, of a physiologic parameter
of an individual patient. The question of
importance to clinicians is whether or not
a knowledge of this factor will affect
diagnosis, treatment planning, or the
aThe Angle
Freeway SPace
treatment stability of a patient's maloc'
clusion. Current treatment modalities for
malocclusion correction include exten-
sive functional orthopedic and surgical
orthodontic treatment methods. Little
research has been done, however, into
what happens to the size of the fwS
before and during treatment' and in the
retention and postretention periods.
Why do cases which appear clinically
similar when utilizing such static
descriptive factors as S-N/MP angle, or
Frankfort/mandibular plane angle,
behave differently during overbite cor'
rection to the point that one case is suc-
cessfully treated while the other is not?
Does the size of the freeway space have
any relevance to the ease of molar extru-
sion in deepbite low angle casesl or, is it
of importance in controlling unwanted
molar extrusion in openbite cases? Fur-
ther research is necessary to investigate
these possibilities.
Summary
- -
fhis study is an attempt to investigate
I the physiologic parameter of free-
way space, and relate it to vertical dimen-
sion. Orthodontists in the past have relied
on static morphometric evaluations to
describe the orthodontic patient, while
analysis on a physiologic basis has been
lacking. In order to fully assess a patient,
studies ofthe clinical physiological capa'
bilities and limitations of a patient's neu'
romuscular status may be necessary for
better diagnosis, treatment planning,
treatment procedures, and postretention
results.
The authors thank Dr. L. V. Christensen Jor his
assisnnce with the statisrical evaluations in this
study, and Daae Mandeaille and Waltrude Steh'
wien for their assistance with the illustations.
-do
Orthodontist April, 1987 153
 Konchak et al.
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