CEPHALOMETRIC

ANALYSIS
DIMENSION
OF OCCLUSION
FRANK

L. BASLER, D.D.S.,

OF THE

JAMES

VERTICAL

R. DOUGLAS, D.D.S.,**

AND ROBERT

S.

MOULTON, D.D.S. * *
Bay Pines, Flu., Memphis,

Term., and Dublin,

Ga.

HE VERTICAL DIMENSION OF OCCLUSION is one of the important

reference points
successful complete denture construction. Numerous techniques are used
to determine this relation, but no reliable method is available to evaluate their
accuracy.
Orthodontists use cephalometric roentgenography, a scientific means of measuring bone growth by comparative measurements of serial roentgenograms, to
trace treatment progress and for study purposes. l A cephalostat was selected as a
measuring aid to study three common methods of recording the vertical dimension
of occlusion,

T in

POSITIONING THE CEPHALOSTAI

The cephalostat was installed in a fixed position, and the bracket that positions
the roentgen tube was mounted at a 60 inch target to film distance. The cephalostat
was focused so that the central rays would pass through the exact center of the
ear pieces that hold the head in position. Pre-extraction cephalometric roentgenograms recording the vertical dimension of occlusion were made.
ROENTGENOGRAPHIC TRACINGS

Tracings of pertinent landmarks, lines, and measurement areas were made

from each roentgenogram. Superimposition of successive tracings was facilitated
by the selection of identical reference points, bone landmarks and drawn lines and
planes (Fig. 1) : (1) the cranial base line, a line drawn from the center of the
sella turcica to the nasion (SN), (2) the Bolton plane, a line drawn from the
Bolton point to the nasion, (3) a line drawn from the sella turcica perpendicular
to the Bolton plane, and (4) the anterior nasal spine. The lines that were used
to locate the point of measurement were (1) the facial line, a line projected from
the nasion through the anterior border of the symphysis, and (2) the mandibular
line, a line paralleling the lower border of the mandible and projected to cross the
facial line. This cross point is identified as 0.
*Staff Dentist, Veterans Administration Center, Bay Pines, Fla.
**Staff Dentist, Veterans Administration Teaching Group Hospital, Memphis, Tenn.
***Career Resident in Prosthodontics, Veterans Administration Center, Dublin, Ga.
831

J. Pros. Den.
Sept.-Oct., 1961

BASLER, DOUGLAS, AND MOULTON

832

The distance in millimeters along the facial line from the nasion (N) to the
cross point is the measurement of the vertical dimension of occlusion. Any vertical
deviation can easily be determined by comparing this measurement with that of
any previous studies made on the same patient.
TECHNIQUES

FOR ESTABLISHING

THE VERTICAL

DIMENSION

OF OCCLUSION

Three widely used techniques were selected to determine the vertical dimension
of occlusion. The results from these techniques were compared with records of the
pre-extraction vertical dimension of occlusion.2
upper occlusion rim was contoured to give
Phonetics and Esthetics .-The
adequate lip support and indicate correct tooth length. The lower occlusion rim
was developed to provide an approximately 3 mm. interocclusal distance. Centric
relation was recorded, and the casts were mounted on a Hanau model H articulator.
Phonetics was considered during the try-in.3

Fig. 1.-A

schematic drawing shows the orientation

landmarks and the location
lines for the measurement of the vertical dimension of occlusion.

of projection

Tactile Muscle Sense.-The same upper occlusion rim and lower acrylic resin
baseplate were used. A softened wax rim was attached to the lower baseplate. The
rims were placed on the articulator, which was slowly closed until the incisal guide
pin was 8 mm. above the incisal guide table. This provided a controlled amount
of wax for the patient to reduce. Then, the wax on the lower baseplate was uniformly softened in warm water and inserted into the mouth with the upper occlusion
rim. The patient was instructed to close the teeth into the wax until he felt that
the jaw separation was similar to his pre-extraction
dimension. Then, centric
relation was recorded.4
Physiologic Deglutition.-The
same procedure as in the tactile sense technique
was followed, except that the patient was asked to touch the softened wax on the
lower baseplate lightly against the upper occlusion rim and then to suck and

Volume
Number

11
5

CEPHALOMETR.[C

ANALYSIS

OF

VERTICAL

DIMENSION

swallow. This procedure was repeated three times. Centric relation

recorded along with the vertical. dimension of occlusion.5
INVESTIGATIONS

AND

833

was usually

SUBJECTS

Two investigations, A and B, carried out independently of each other, involved

use of all three techniques on each subject. Accordingly, one pre-extraction record
of the vertical dimension of occlusion and six subsequent records of the vertical
dimension of occlusion were made for each of 26 subjects selected to participate in
this study. Thus, a total of 156 records, not including the pre-extraction records,
were made.
Investigation A, which was done by a single dentist, consisted of use of all
three techniques on all subjects. In investigation B, three other dentists worked together for added fluidity and as a cross check. At no time did any dentist see any
of the roentgenograms until his series was completed.
No attempt was made to select subjects according to age group, cooperativeness, or whether or not they were potentially good denture patients. The only
criteria considered were (1) a need for the extraction of all remaining natural
teeth and (2) sufficient posterior tooth contacts in harmony with centric relation
to maintain a relatively normal vertical dimension of occlusion. The study was
started 3 months after the last teeth were extracted.
.
RESULTS

Reducing the interocclusal distance more than 1 mm. from normal is usually
considered undesirable. Since reducing the vertical dimension of occlusion increases
the interocclusal distance, a 1 mm. reduction of the vertical dimension was considered acceptable. The spread of 2 mm. from -1 to +l mm. seemed to be within
a normal range, and it was acc:epted as correct for purposes of comparison. The
variations between the established vertical dimension of occlusion and the preextraction relation are seen in Table I.
There was a great variation between the number of registrations of the vertical
dimension accepted as correct (27.5 per cent) and those found to be decreased
(58.7 per cent) (Table II). The number of registrations that were increased 2
mm. or more (13.4 per cent) was similar to those decreased 5 mm. or more (14.7
per cent). Technique 3 seemed to be slightly more desirable in the number of
correct registrations recorded (32+ per cent), with a lesser number of instances
of decreased vertical dimension of occlusion (51 per cent). However, technique 3
also resulted in the greatest number of increased vertical dimensions of occlusion
recorded ( 15 per cent), as compared to techniques 1 and 2 and to the over-all
average (13.4 per cent). The twenty-three closed registrations included in the
5 mm. or more category fell mainly into two major groups, one a group of 9
subjects measuring 5 mm. and the other a group of 8 measuring 8 mm. The remaining registrations were from 6 mm. to 13 mm.
One wonders how the vertical dimension of occlusion could be decreased as
much as 13 mm. (Table I, patient 21). However, with this patient, in investigation

834

BASLER,

DOUGLAS,

AND

J. Pros.
Sept..Oct.,

MOULTON

Den.
1961

A, there were two registrations at -7 mm. and one at -8 mm; in B, two at -11
mm. and one at -13 mm. Interestingly enough, of the twenty-one registrations
that were increased 2 mm. or more, none were increased 4 mm. or more.
SUMMARY

Three commonly used techniques to establish the vertical dimension of occlusion

were tested. Cephalometric roentgenography was used to record and evaluate their
comparative accuracy.
A number of dentists participated in the clinical phase of the investigation to
obtain as unbiased a pattern as possible and to be a check upon each other.
CONCLUSIONS

1. Cephalometric roentgenography can be used to measure and evaluate the

accuracy of different techniques used to establish the vertical dimension of occlusion.
2. The most common error found by recording the vertical dimension of
occlusion by all methods tested was excessive overclosure (58.7 per cent).
3. A variation in the results of the three techniques was anticipated, but the

TABLE I.

DIFFEKENCES IN MILLIMETERS BETWEEN PRE-EXTRACTION AND POSTEXTRACTION

RECORDSOFTHEVERTICAL
DIMENSIONOF~CCLUSION

TECHNIQUE

TECHNIQUE 2

PATIENT

--

TECHNIQUE 3
A

Volume
Number

11
5

CEPHALOMETRIC

II.

TABLE

ANALYSIS

THIS CONSOLIDATED

Z-Z=
I
-

VERTICAL
DIMENSION
OF
OCCLUSION

TECHNIQUES

Increased
2 mm. and over

Correct
-1 to+1

mm.

Decreased
2,3, and 4 mm.

13

- -

.+I

A
-

5 mm. and ovex

RESULTS

835

DIMENSION

AND PERCENTAGES

AND INVESTIGATIONS
TOTALS

---

OF VERTICAL

- - - A
-

B
-

__ -. - - -

A.+ B
__.

--

--

A
-

_--

A
_-

+E

IrT0.
%
- ._--

13+

11+

21

13.4

13

24-k

13

24+

11

17

32+ 43

27.5

11

24

46

11

12

23

44

14

22

42

44.0

10

19

1%
-

- -

- -

69
23
-. -

14.7
I

difference between dentists using the same technique on the same patient was of
little clinical significance.
4. With a few exceptions, if in investigation A the vertical dimension of occlusion was increased or decreased in the recordings, B was parallel in these recordings
to a greater or lesser degree.
5. There was insufficient difference between techniques tested to set one
aside as the outstanding technique.
6. The techniques studied appear to seriously require additional research and
refinement to improve accuracy.
Dr. John E. West, Staff Dentist, Veterans Administration Hospital, Mountain Home,
Tenn., gave valuable assistance in the early phases of this study. Acknowledgment also is given
to Mr. Herbert C. Schonert for the art work and to Mr. Alex Gravesen, Chief, Medical Illustration Service, Veterans Administration Medical Teaching Hospital, Memphis, Tenn.
REFERENCES

1. Kazis, H., and Kazis, A. J.: Complete Mouth Rehabilitation Through Crown and Bridge
Prosthodontics, Philadelphia, 1956, Lea & Febiger, pp. 90-109.
2. Willie, R. G.: Trends in Clinical Methods of Establishing an Ideal Interarch Relationship,
J. PROS. DEN. 8:243-251, 19.58.
3. Silverman, M. M.: Accurate Measurement of Vertical Dimension by Phonetics and the
Speaking Centric Space, D. Digest 57:261-265, 308, 19.51.
4. Niswonger, N. E.: Obtaining Vertical Dimensions in Edentulous Cases That Existed Prior
to Extraction, J.A.D.A. 25:1482-1487, 1938.
5. Gillis, R. R.: Establishing Vertical Dimension in Full Denture Construction, J.A.D.A.
28:430-436, 1941.
VETERANS ADMINISTRATION
BAY PINES, FLA.

CENTER

VETERANS
MEMPHIS,

ADMINISTRATION
TENN.

TE.~CHING

ADMINISTRATION

CENTER

VETERANS
DUBLIN,

GA.

GROUP HOSPITAL