Kinesiographic study of the mandible in young patients ...hera.ugr.es/doi/15027223.pdf ·...

It is commonly believed that unilateral posteriorcrossbites (UPCB) are associated with postural

problems that may develop into musculoskeletal prob-lems in adults.1-5 Early treatment has been recom-mended because spontaneous correction is unusual.6-9

If this malocclusion is left untreated, skeletal remodel-ing may occur over time and the mandibular deviationtoward the crossbite side may persist.10,11

In children, UPCB is normally accompanied by a lat-eral functional shift of the mandible from maximumopening to centric occlusion (CO).10 Generally, this shiftof the mandible is also compensated for by adaptationswithin the neuromuscular system.12 In a previousstudy,13 we reported a significant degree of muscularasymmetry at rest and during function. This asymmetricmuscular activity at rest (without cuspal interferences)may indicate a permanent displacement of the mandible.However, studies assessing the range of jaw movementsduring different physiologic activities, such as chewingand swallowing, and during other functional mandibularmovements and positions, including lateral excursions,

protrusive, maximum opening, and resting posture, arelacking. The quantitative analysis of these movementswould allow a better understanding of the neuromuscu-lar response and the effects on jaw function in patientswith this malocclusion.

The purpose of this study was to assess the positionat rest as well as the dynamic activity of the mandible inchildren with unilateral posterior crossbite and to com-pare it with a sample of children with normal occlusion.

SUBJECTS AND METHODSPatient Population

A consecutive sample of 60 white subjects visitingthe Children’s Department of the Faculty of Odontol-ogy of University Complutense, Madrid (Spain) wascollected and divided into 2 groups. The control groupconsisted of 30 subjects (16 girls and 14 boys, meanage 12 years 5 months) with normal occlusion, and theexperimental group consisted of 30 subjects (17 girlsand 13 boys, mean age 12 years 2 months) with rightposterior crossbite of at least the first permanent molar.

The entrance criteria established for the 2 groupswere age (between 10 and 14 years), skeletal Class Irelationship (according to ANB angle, convexity, andWits appraisal) and mesofacial growth pattern (accord-ing to Frankfort horizontal-to-mandibular plane angle).Subjects were excluded if they presented clinical signsor symptoms of temporomandibular joint dysfunction,skeletal asymmetry (based on submentovertex radi-

aAssociate Professor of Orthodontic, University Complutense. bAssociate Professor of Orthodontic, University of Granada.cProfessor of Orthodontics, University Complutense.Reprint requests to: Conchita Martín. C/ Bola del Mundo, 38 28023 Madrid,Spain; e-mail, [email protected], December 1999; revised and accepted, March 2000.Copyright © 2000 by the American Association of Orthodontists.0889-5406/2000/$12.00 + 0 8/1/109494doi.10.1067/mod.2000.109494

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ORIGINAL ARTICLE

Kinesiographic study of the mandible in young patients withunilateral posterior crossbite

Conchita Martín, DDS, PhD,a José Antonio Alarcón, DDS, PhD,b and Juan Carlos Palma, MD, PhDc

Madrid, Spain

It is generally assumed that children with posterior crossbites have abnormal mandibular movements;however, this assumption has not been clearly evaluated. The purpose of this investigation was to study themovements and the resting position of the mandible in 2 samples of 30 subjects, one aged 10 to 14 years withright posterior crossbite, the other aged 10 to 15 years with normal occlusion. Subjects in both groupsexhibited a Class I skeletal relationship and mesofacial growth pattern. A mandibular kinesiograph was usedto record both the mandibular resting position and dynamic movements. Mandibular movements wererecorded during (1) maximum excursions (opening-closing, protrusion, right and left excursions), (2)swallowing, and (3) mastication. The results showed no differences between groups in the extension of themovements during closing and protrusion. However, crossbite patients exhibited a significant lateral shiftduring these movements. Right and left excursions were also similar between groups. The dimension of thefreeway space was similar between groups, but the lateral shift found in centric occlusion was also present inthe crossbite group when the mandible was at rest. The crossbite group more frequently showed a pattern ofabnormal swallowing. No differences were found in any of the parameters studied during the masticatorycycle. There was no relationship between the side of the crossbite and the masticatory preference side. Inconclusion, posterior crossbite patients showed a lateral shift in some movements that persisted when themandible was at rest. (Am J Orthod Dentofacial Orthop 2000;118:541-8)

CE

542 Martín, Alarcón, and Palma American Journal of Orthodontics and Dentofacial OrthopedicsNovember 2000

ographs), previous or current orthodontic treatment,extensive restorations, cast restorations or cuspal cov-erage, pathologic periodontal conditions, or missingteeth. The presence or absence of a lateral shift on clo-sure was not considered an entrance criterion.

All subjects received full explanations of the aimsand the design of the study before its start and agreedto participate by signing an informed consent.

Kinematic recordings

Mandibular movements were recorded using a kine-siograph computer system (K6, Myo-Tronics, Seattle,Wash). This system allows a 3-dimensional (vertical,anteroposterior, and lateral) recording of jaw movementsto be made without interfering with the motion of thejaw. To record movements, this system uses a sensorarray strapped to the patient’s head that tracks the spatiallocation of a magnet mounted on the mandibular incisorsby means of a medical adhesive (Urihesive, Squibb). Theposition of the magnet attached to the buccal surfaces ofthe lower central incisor is set at zero in CO. The arrayof sensing devices is placed parallel to the Frankfort hor-izontal and at a right angle to the midsagittal and frontalplanes, which serves as reference planes for all move-ments. The patient should sit erect with adequate lumbarsupport and should be free of ferromagnetic material.For the placement of sensors, the alignment and calibra-tion of the instruments, and the recording and display ofdata we followed the manufacturer’s protocol.14

Mandibular position was recorded at rest and dur-ing jaw movements in maximum excursions (open-ing–closing, protrusion, and right and left lateral excur-sions), during swallowing and during chewing, byusing the protocol described below.

At rest. To obtain the mandibular rest position, with-out occlusal contact, the patient was asked to moisten hisor her lips, swallow saliva, breathe deeply, and relax hisor her jaw with eyes closed. After recording in this posi-tion, the patient was asked to close to habitual occlusionand the vertical, anteroposterior, and lateral displace-ments as the mandible moved upward from the rest posi-tion to habitual centric occlusion were recorded (Fig 1).

Maximum excursions. To obtain a reading for max-imum excursion (Fig 2), the patient was asked to openas wide as possible and close back to CO. Simultane-ous sagittal and frontal traces of the trajectory of a sim-ple opening and closing of the mouth were recorded(Fig 3A and B). Then the patient was asked to slide thejaw forward as far as possible, then back to CO. Spe-cial attention was paid to the presence of lateral shiftsduring these movements. Finally, the patient was askedto slide the jaw to the left as far as possible and thenback to CO, then to the right and back (Fig 4).

In order to measure the degree of lateral deviationthat the mandible exhibited at rest, we subtracted thelateral shift of the mandible from rest position to COfrom the lateral shift occurring from maximum open-ing to CO (Fig 3C).

Swallowing. The swallowing mandibular movementwas recorded during the intake of water. The subjectwas instructed to take a mouthful of water, swallow it,and then to close to habitual position. This protocol wasspecifically designed to determine if the patient wasswallowing normally, with the teeth braced together inCO (Fig 5A, adult swallowing), or whether mandibularbracing occurred, with the tongue held between theteeth (Fig 5B, immature swallowing). Whenever theend-point of the swallowing movement was not coinci-dent with habitual position, we identified tongue thrust.The distance the trace traveled from the end-point ofdeglutition to habitual position represents the amount oftongue held between the teeth during the swallow.

Chewing. Mandibular chewing movement was reg-istered during the mastication of chips. The operatorasked the subject to eat chips, but gave no furtherinstructions. The following variables were studied:maximum opening, maximum lateral displacement,maximum amplitude, and maximum mandibular retru-sion during the cycle (Fig 6). A preference for the rightor left side was determined after considering the chew-ing strokes in the frontal plane, using the preferenceindexes described by Wilding and Lewin.15

Several trial tests were made to instruct the patient.If irregular or spurious traces were present, they wereomitted and the measurements repeated.

One examiner performed all kinesiographic mea-surements in a “blind” manner, ie, unaware of the pres-

Fig 1. Shows 3-dimensional movement (vertical, antero-posterior, lateral) of the mandible from rest position tohabitual occlusion.

American Journal of Orthodontics and Dentofacial Orthopedics Martín, Alarcón, and Palma 543Volume 118, Number 5

Fig 2. Opening-closing movements of (A) control and (B) UPC patient.

Fig 3. A, Sagittal and B, frontal trace of the opening-closing trajectory; C, degree of lateral deviation of the mandible at rest.

A B C

Fig 4. A, Sagittal and B, frontal trace of protrusive trajectory; C, lateral excursions.

A B C

A B


ence of a posterior crossbite. Each subject was given acode number and the group assignment was notrevealed until all the data had been compiled.

Reproducibility of Measurements

In order to evaluate the reproducibility of the kine-siographic records, the results of 2 consecutive measure-ments of opening-closing movement of 10 randomlyselected subjects on vertical and lateral displacementswere compared. Data from the first tracing were com-pared with data from the second for statistical signifi-cance with the Student t variable test.

Statistical Analysis

Means and standard deviations were calculated forthe kinesiographic values. Data were compared betweengroups using parametric statistics (Student t test). Chi-squared test was used to determine the relationship

between the crossbite side and the preference index. Sig-nificance was set at the 5% level (P ≤ .05). These testswere carried out with statistical analysis software(BMDP6D Statistical Software, Inc, Los Angeles, Calif).

RESULTS

As Table I shows, differences between repeatedrecordings of mandibular movements were not statisti-cally significant.

Table II shows the 3 outcome variables consideredin the analysis of the rest position: vertical freewayspace, anteroposterior displacement, and lateral shift.There were no differences between groups for any ofthese variables.

When assessing the movement of mandibular open-ing-closing, 2 outcome variables were considered: thevertical opening and the lateral shift occurring frommaximum opening to CO. (Since skeletal asymmetries

Fig 6. (A) Sagittal and (B) frontal trace of the masticatory cycle.

A B

Fig 5. Tracing of (A) an adult and (B) an immature swallowing pattern. Cross (+) shows the end point of deglutition.

A B


were excluded, we considered that the functional shiftsdisappeared in maximum opening.) The vertical open-ing was similar in the two groups (33.36 mm, SD 2.19mm in the control group vs 34.02 mm, SD 1.98 mm).The crossbite group exhibited a lateral functional shiftduring closure toward the crossbite side of 2.95 mm(SD 1.13 mm) that was significantly greater (P < 0.05)than in the control group (1.06 mm, SD 2.60 mm).

The difference between the lateral shift from maxi-mum opening to CO and the lateral shift from rest posi-tion to CO was 2.95 mm (SD 1.78 mm) in the crossbitegroup and 0.93 mm (SD 1.36 mm) in the control group,a statistically significant difference (P < .05).

When assessing the movement of mandibular pro-trusion, 2 outcome variables were considered: the ante-rior displacement and the lateral shift. The anterior dis-placement was similar between groups (5.44 mm, SD2.34 mm in the control group vs 5.95 mm, SD 2.63 mmin the crossbite group). However, there was a lateralshift toward the noncrossbite side during protrusion inthe crossbite group (–1.38 mm, SD 1.68 mm) signifi-cantly higher (P < .01) than in the control group (0.06mm, SD 1.07 mm).

Table III shows the kinesiographic data found duringlateral mandibular movements. No significant differencesbetween groups were found during lateral excursions.

The percentage of patients showing an immatureswallowing pattern was calculated in each group. Fiftypercent of the patients with posterior crossbite exhib-ited an immature swallowing pattern, whereas only26.67% of the control patients were affected (P < .01).

None of the 4 kinesiographic variables of the mas-ticatory cycle were significantly different between theexperimental and the control groups, as shown in TableIV. Regarding the preference indexes, differencesbetween groups were not statistically significant. Therewas no relationship between the side of the crossbiteand masticatory preference (P = 1).

DISCUSSION

In children with functional unilateral posterior cross-bite, the mandible usually shifts laterally toward the cross-bite side. This is generally the result of both poor inter-digitation and occlusal interferences.16 Because one of ourobjectives was to assess if this lateral shift persisted dur-ing the resting position of the mandible, we excluded fromour sample those subjects with skeletal asymmetries of themandible (based on submentovertex radiographs).

We measured all mandibular movements with akinesiograph. This system is a simple method of mea-suring jaw movements. A magnet is fixed to the facialsurface of the mandibular incisors, so there is no discom-fort or reason to stabilize the head. In addition, different

Table I. Comparison of the kinesiographic data (mm) taken2 consecutive times during opening-closing movements

First tracing Second tracing Student t

Parameter Mean SD Mean SD P

Vertical opening 33.70 2.29 33.54 2.18 0.29 NSLateral shift 1.96 0.99 2.01 1.13 0.87 NS

Table II. Means and standard deviations of the kinesio-graphic data (mm) at rest position and comparison betweennormocclusive group and right posterior crossbite group

Normocclusive Right posterior Student group crossbite group t


Vertical freeway 2.63 1.38 2.70 1.13 0.86 NSspace

Anteroposterior 0.70 0.84 0.85 0.81 0.47 NSdisplacement

Lateral 0.13 0.43 0.00 0.56 0.37 NSdisplacement

Table III. Means and standard deviations of the kinesio-graphic data (mm) of lateral excursions and compari-son between normocclusive group and right posteriorcrossbite group



Right lateral 6.81 1.27 6.91 1.08 0.67 NSexcursion

Left lateral –6.52 0.98 –7.61 1.22 0.34 NSexcursion

Table IV. Means and standard deviations of the kinesio-graphic data (mm) of mastication and comparisonbetween normocclusive group and right posterior cross-bite group



Maximum 17.87 4.48 16.85 4.02 0.47 NSopening

Maximum lateral 5.97 2.02 5.70 2.39 0.58 NSdisplacement

Maximum 9.10 3.02 8.65 3.64 0.61 NSamplitude

Maximum 6.50 2.86 6.05 2.14 0.55 NSmandibularretrusion

Right preference 61.27 34.14 60.65 37.24 0.94 NS(% of cycles)

Left preference 38.73 34.14 39.35 37.24 0.94 NS(% of cycles)


authors have studied the accuracy of measuring mandibu-lar movements by studying the movements at the man-dibular incisors, and they have concluded that the linear-ity and quantitative accuracy ranged from an error of 0mm at intercuspidation to a maximum of 0.1 mm.17,18

Among the advantages of this technique are the ability ofmandibular incisor movement to reflect a full range ofmandibular motion without interfering with physiologicfunctions, the ability of individuals in a normal range tohave precise proprioception, and the ease of access.19

At rest, no statistical differences between the con-trol and crossbite subjects were found with the 3 vari-ables measured. Freeway space ranged from 2.63 mmto 2.7 mm. These dimensions are within the normalrange of variability defined in previous studies.14,20-23

The similarity in the freeway dimensions in the groupscould be due to the fact that all patients presented amesofacial growth pattern and skeletal Class I relation-ship. Different authors have stated that the verticaldimension is smaller in dolicofacial patients than inbrachyfacial subjects.24-26 Other possible sources ofvariation are the position of the head, the loss of teeth,emotional tension, aging, and breathe pattern.23,27,28

The results confirm that the UPCB does not affect thevertical dimension of the freeway space.

The transversal analysis of rest position offered dif-ferences between groups. The lateral shift from rest toCO was 0.13 mm in the control group and 0 mm in thecrossbite group. This implies that if the mandible wasdeviated at CO, the deviation persisted in the rest posi-tion. This could explain the asymmetry in the activityof the posterior temporalis muscles found at rest in dif-ferent studies.13,29-31

The maximum vertical opening was similar in thegroups. Our values were slightly smaller than thosereported by Ferrario et al20 and Ishigaki et al,32 but higherthan those found by Nielsen et al.21 It is difficult to com-pare the data from different studies because the protocolsand techniques used for measuring jaw movements arenot the same. First of all, our data were collected duringfunctional cycles of opening-closing movements withoutforcing a maximum opening beyond the functional rangeof jaw movement. Furthermore, the mean age of ourpatients was in all cases younger than in other studies.

There is no agreement regarding the clinical impli-cations of the dynamic evaluation of mandibular move-ments to the diagnosis of temporomandibular disor-ders. After comparing the extension of maximumopening in healthy subjects and dysfunctional patients,some authors did not find significant differences,21,33

whereas others did.34,35

The second variable studied during opening-closingmovement was the lateral shift. We considered that at

maximum opening the mandible was not deviatedbecause there was no skeletal asymmetry. The lateralshift found in the control group (1.06 mm) can be con-sidered within the normal range of variability, asreported in other studies.19,20,32 The lateral shift foundin the crossbite group was significantly greater (2.95mm toward the crossbite side). This variable was usedto determine the degree of deviation that persisted inthe rest position. We calculated the difference betweenthe lateral shift from maximum opening to CO and thelateral shift from rest position to CO. Results showed asignificant difference between groups, indicating thatin the crossbite group, the mandible was deviatedtoward the crossbite side at rest and in the absence oftooth contacts. This fact confirms the hypothesis thatthe asymmetry in activity of the posterior temporalismuscles found at rest in different studies13,29-31 couldbe explained by this deviation.

The extension of the anterior protrusive movementfrom CO was similar in the 2 groups, but the crossbitepatients exhibited a lateral shift toward the noncrossbiteside that was significantly different from the controlgroup. A possible explanation could be that during theprotrusive movement, posterior tooth contacts are elimi-nated and the mandible is anteriorly guided by the incisalcontacts only, so the deviation present at CO is corrected.

Right and left lateral excursions were similar in the2 groups. In crossbite patients, we found that the lateralexcursion toward the noncrossbite side was greaterthan excursions toward the crossbite side, but the dif-ferences were not statistically significant.

Immature swallowing was more frequent in the cross-bite patients (50%) than in the control subjects (26.67%).Occlusal interferences that are normally present in UPCBpatients may act as stimuli during swallowing,36 causinga person to place the tongue between the teeth to providejaw stability and avoid pain. Immature swallowing couldalso be related with the etiology of UPCB. Tongue thrustduring swallowing reduces the tension of the tongueagainst the maxilla, whereas there is an increase of thetension of the perioral and buccinatory muscles againstthe maxillary dental arch. This could slow the normaltransversal development of the maxilla.

None of the 4 kinesiographic variables studied in themasticatory cycle was significantly different betweenthe experimental and control groups. These resultsshowed that the dimensions of the masticatory cycle arenot essentially different in patients with posterior cross-bite. This does not mean, however, that the masticatorypattern is similar in both groups because there are othervariables, such as opening velocity or cycle type, thatalso need to be analyzed.37,38 Our results are in agree-ment with the findings of other investigators.39,40


Regarding preference indexes, differences betweengroups were not statistically significant. Resultsshowed that there was no relationship between the sideof crossbite and masticatory preference. These findingsare in agreement with those of Goldaracena et al,41 butare different from the ones obtained by Egermark-Eriksson et al,42 who found that crossbite subjects pre-ferred to chew unilaterally. In our opinion the effect ofthe UPCB on mastication depends on the degree of theocclusal stability achieved.

CONCLUSIONS

Kinesiographic recordings of the rest position of themandible and its dynamic movements during 4 maxi-mum excursions, swallowing, and mastication from 30right crossbite patients and 30 control subjects were com-pared. Results revealed no differences in the extension ofthe movements of closing and protrusion between the 2groups, but crossbite patients exhibited a lateral shift dur-ing these movements. Right and left excursions weresimilar in both groups. The dimensions of the freewayspace did not show differences between groups, but thelateral shift found in centric occlusion was also presentwhen the mandible was at rest in children with posteriorcrossbite. An abnormal swallowing pattern was more fre-quent in crossbite patients than in controls. No differ-ences were found in the parameters of the masticatorycycle. There was no relationship between the side of thecrossbite and the masticatory preference side.

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