Diagnosis of the Vertical Dimension

James L. Vaden and Lloyd E. Pearson

The vertical dimension problem is complex and multifactorial, Not only

must the clinician recognize a vertical discrepancy abnormality, he/she must
be able to recognize its numerous components and understand their inter-
relationships, Many scientific investigators and orthodontic clinicians have
contributed to the body of knowledge to which we have access. This article
reviews some of the pertinent literature and offers some diagnostic and
treatment planning suggestions to the clinical specialist who struggles with
the vertical dimension enigma on a daily basis, (Semin Orthod 2002;8:
120-129,) Copyright 2002, Elsevier Science (USA). All rights reserved.

he h u m a n face has been the subject of
T study since man could first express himself.
As civilizations have risen and subsequently
faded away, one thing that has remained is art,
in most cases, drawings, paintings, and so on of
faces. During the Renaissance, da Vinci, Michae-
langelo, and D u h r e r led o t h e r artists to study
faces. Facial p r o p o r t i o n was discovered; there
were standards set for balance and h a r m o n y of
the lower face. In our specialty of orthodontics,
Angle was vitally c o n c e r n e d about the face. In
his sixth edition, 1 he states, "One of the evil
effects of malocclusion is the marring or distort-
ing of the normal facial lines. It follows that, in
the application of the principles of orthodontia,
our efforts should be so directed as to mold and
modify these lines of i n h a r m o n y to those of
h a r m o n y and facial beauty so far as lies within
the range of the possibilities of art, and of the
type and t e m p e r a m e n t of the individual. O u r
opportunities for benefiting humanity are very
great in this field, far exceeding those offered by
any other branch of dental science, for patients
with facial lines so distorted as sometimes to be
a marked deformity and a source of constant
humiliation to themselves and their friends may
Prom the Department of Orthodontics, University of Tennessee,
Memphis, TN; and a Private Practice, Edina, MN.
Address cor~rspondence to James L. Vaden, DDS, M8, Depart-
ment of Orthodonti~, University of Tennessee, Health Seienee Cen-
ter, 875 Union Avenue, Memphis, TN 38163.
Copyright 2002, Els~ier Science (USA). All rights trserved.
1073-8746/02/0803-0003535.00/0
doi:l O.1053/sodo. 2002.125431
now be so treated as to bring about a complete
transformation of the facial expression, even to
the establishment of lines of beauty."
Tweed revolutionized orthodontic diagnosis
because of his c o n c e r n for the balance and har-
m o n y of the lower face. Many in our specialty
have studied the face, z-6 developed diagnostic
guidelines for quantifying facial balance, 7-u and
proposed treatment regimens that give the orth-
odontic clinician a greater certainty that facial
balance and h a r m o n y is an attainable goal for
their patients.
The underlying theme that surfaces from all
artists and orthodontic investigators is the con-
cept that there c a n n o t be good balance and
h a r m o n y in the lower face unless the vertical
dimension is within normal limits. The most
important prerequisite for facial balance is a
normal vertical dimension of the lower face.
Poulton 12 c o n d u c t e d a study on cervical traction
and f o u n d that large lower anterior facial
heights were most often associated with a dis-
pleasing face. In their article on soft-tissue pro-
file preference, DeSmit and DermauO 3 created
three different series of nine profile photo-
graphs so that a total of more than 200 profiles
could be ranked by graduate dental students.
They f o u n d that differences in gender and orth-
odontic knowledge of the students seemed to
have no significant influence on their esthetic
preference. The results of their study confirmed
the importance of anteroposterior deviations
but suggested that unaesthetic facial profiles
that were a result of anteroposterior deviations
were completely overshadowed by long-face fea-

120 Seminars in Orthodontics, Vol 8, No 3 (September), 2002: pp 120-129

 Diagnosis of the Vertical Dimension
t u r e s - - t h e long-face feature being m o r e unaes-
thetic. Because of the challenge of the vertical
dimension, the subject of this article is of ex-
treme i m p o r t a n c e to the orthodontic specialist.
Not only must the specialist recognize the prob-
lem, the specialist must u n d e r s t a n d the diagno-
sis of the p r o b l e m so that all facets and compo-
nents of the vertical dimension e n i g m a are
understood. T h e clinician must be able to rec-
ognize the various c o m p o n e n t s of a vertical di-
mension abnormality and u n d e r s t a n d the inter-
relationship of all the elements of the problem.
Before discussing the abnormal, it is p r u d e n t
to understand the normal. Two of the most ac-
cepted descriptions or publications of vertical
facial proportions have b e e n published by Fra-
kas 14 and Frakas and Munro. 15 In these, they
describe the ideal face as vertically divided into
equal thirds by horizontal lines that approxi-
mate the hairline, the bridge of the nose, the ala
of the nose, and m e n t o n (Fig 1)J 6 Figure 1 also
shows that in the ideal vertically p r o p o r t i o n e d
face there is a further division of the lower one
1/3
113
113
Figure 1. The ideal facial proportions as described
by Frakas 14 and Frakas and Munro. 15 The frontal
view of the face is divided into equal thirds by
horizontal lines that approximate the hairline, the
bridge of the nose, and the ala of the nose and
menton. The lower third is further divided into an
upper third and a lower two third.
121
third of the face into an u p p e r one third and a
lower two third. These divisions of the face can
be used by the clinician to help diagnose vertical
dimension problems. For example, does a pa-
tient have a disproportionately long lower facial
height because of vertical maxillary excess or to
excessive chin height? Conversely, is a short fa-
cial height caused by vertical maxillary defi-
ciency or a short chin height? 17 By using these
accepted proportions as a guide, the patient
shown in Figure 2 has an excessive lower ante-
rior facial height, whereas the patient shown in
Figure 3 has diminished lower anterior facial
height. Although it is evident that both have
vertical dimension abnormalities by looking at
the face, measuring the facial proportions con-
firms this intuitive conclusion. A careful deter-
mination of the vertical proportions of the face
is therefore the first step in the diagnosis of a
vertical dimension problem.
Role of Skeletal and Dental
Relationships
After examining the face and quantifying its pro-
portions, the skeletal pattern and the teeth and
their relationships to each other must be scruti-
nized. However, a diagnosis of the vertical di-
m e n s i o n is m o r e complicated because vertical
discrepancy malocclusions are nmltidimen-
sional. For example, dentoalveolar abnormali-
ties can impact the skeletal pattern, and p o o r
skeletal patterns can cause dentoalveolar com-
pensations that are difficult for the clinician to
correct. T h e following variations can be present,
either alone or in combination: (1) maxilla:
maxillary posterior alveolar excess and inferiorly
positioned maxilla and (2) mandible: mandibu-
lar posterior alveolar excess and short mandib-
ular rami. O t h e r abnormalities may include
superiorly positioned condylar fossa, obtuse cra-
nial base angle, and condylar resorption.
Any of these conditions, with or without ab-
errant m a n d i b u l a r growth rotation, can be a
causative factor in the vertical discrepancy mal-
occlusion.
Condylar Growth
A c o m m o n scenario affecting the skeletal prob-
lem is m a n d i b u l a r growth a n d growth rotation,
which unfavorably impacts dentoalveolar devel-
122 Vaden and Pearson
o p m e n t in both the maxilla and mandible.
Bjork is-21 and Bjork and Skieller 2:~,24 have per-
f o r m e d n m n e r o u s studies that have shown that
the most c o m m o n direction of condylar growth
is vertical, with some anterior c o m p o n e n t . Pa-
tients with a p r o n o u n c e d short lower anterior
facial height (Fig 4A and B) generally exhibit
upward and forward condylar growth (Fig 5).
These individuals generally have a d e e p vertical
overbite with a d e e p mentolabial sulcus and a
strong overclosed appearance. 25 In contrast, pa-
Figure 3. An example of a
patient with a diminished
lower facial height.
Figure 2. An example of a
patient with an excessive
lower facial height.
tients with long-face syndrome (Fig 6A and B)
have a m o r e posteriorly directed growth pattern
of the m a n d i b u l a r condyle (Fig 7). 26,27 These
backward growth rotators have increased ante-
rior facial height, a m o r e posterior position of
the chin, and in e x t r e m e cases, an anterior o p e n
bite may develop. Serial images of the patient
taken to m o n i t o r the direction of condylar
growth would be very useful for the diagnosis of
vertical growth. At the present time, serial imag-
ing poses certain concerns, most significantly
 Diagaosis of the Vertical Dimension
Figure 4. A patient with a pro-
nounced short lower anterior fa-
cial height. (A) The cephalomet-
ric radiograph is also shown. (B)
radiation exposure. Advances in imaging tech-
nology may, in the future, p e r m i t the clinician to
use these m e t h o d s for diagnostic purposes with
greater safety.
An understanding of the maxillomandibular
growth rotation of the patient would be most
helpful in the diagnosis of vertical variations.
Bjork u8 has contributed information that offers
some guidelines for the clinician to assist in the
determination of the growth rotation of the
mandible so that the c o n c o m i t a n t vertical
changes are m o r e easily understood. Bjork's
123
m e t h o d of prediction of condylar growth rota-
tion from a c e p h a l o g r a m offers the clinician
some guidelines. Bjork identified seven specific
structural features that m i g h t develop as a result
of r e m o d e l i n g during a particular type of growth
rotation. Bjork's suggestions for predicting con-
dylar rotation have, however, not b e e n widely
used by the specialty because (1) some of the
indicators cannot be easily seen on the average
cephalogram, (2) the use of the indicators is vmT
time-consuming for the clinician, and (3) there
has b e e n no scientific validation of the suggested
124
Figure 5. An example showing upward and forward
condylar growth.
indicators because of difficulties e n c o u n t e r e d in
study design. Some in the specialty also question
whether several of the suggestions are valid in-
dicators of a particular type of growth rotation.
However, when used for their intended purpose,
as guidelines only, the indicators have some use-
ful clinical applications in the diagnosis of the
patient with vertical dysplasia (Table 1).
Using Bjork's guidelines, it is interesting to
study Figures 4B and 6B. Figure 4B, the forward
rotator, exhibits several of Bjork's indicators in-
cluding observations that (1) the condylar head
curves forward, (2) the mandular canal is
curved, (3) the symphysis has a backward cant,
(4) the interincisal angle is obtuse and, (5)
lower anterior facial height is short. Figure 6B,
Table 1. Bjork's Seven Structural Guidelines 2s
Inclination of the condylar head
Curvature of the m a n d i b u l a r canal
Shape of the m a n d i b u l a r lower border
Inclination o f the symphysis (Anterior aspect j u s t below "B" point)
Interincisal angle
l n t e r p r e m o l a r or intermolar angles
Anterior lower face h e i g h t
Vaden and Pearson
the backward rotator exhibits (1) a straight in-
clination of the condyle, (2) a relatively straight
mandibular canal, (3) the symphysis slopes for-
ward and, (4) lower anterior facial height is
long.
Isaacson, 29 Isaacson et al, 3 and Schudy, ~ fol-
lowing on Bjork's reports, studied jaw rotation
caused by vertical condylar growth. A succinct
summary of the findings of these investigators is
that a forward mandibular rotation occurs when
vertical condylar growth exceeds the sum of the
vertical growth of the maxillary sutures and the
maxillary and mandibular alveolar processes. If
growth of the maxillary sutures and the maxil-
lary/mandibular alveolar processes exceeds ver-
tical condylar growth, a backward rotation
occurs, and the face becomes longer. An under-
standing of the effect of condylar growth on
mandibular position is fundamental if the clini-
cian is to adequately and appropriately diagnose
a vertical dimension abnormality.
Anterior and Posterior Facial Height
Vertical dimension skeletal abnormalities are
not solely caused by condylar growth direction.
They are also caused by differences in anterior
facial height and posterior facial height develop-
ment. These differences in height development
can lead to rotational growth or to changes in
mandibular position that greatly influence the
position of the chin. ~ Etiologies influencing un-
favorable differences in development of anterior
and posterior facial height are nmltifactorial.
These factors can, for simplicity, be subdivided
into those caused by (1) dentoalveolar develop-
m e n t and (2) environmental factors.
Dentoalveolar Development
Issacson et al 3~ studied dentoalveolar develop-
m e n t in three groups of subjects--those with
Fo~t~ard Pvotator Backward Rotator
Cupees forward a n d back Straigbt or slopes u p
Curved Straight
Curved downward Notchcd
Slopes backward Slopes fi)iveard
Vertical or obtuse Acute
Vertical or obtuse Acute
Short Tall
 Diagnosis of the Vertical Dimension
Figure 6. An example of a pa-
tient with long-face syn-
drome.
short anterior facial height, those with average
anterior facial height, and those with excessive
anterior facial height. T h e a m o u n t of maxillary
posterior alveolar d e v e l o p m e n t was t o u n d to de-
crease as the MP-SN angle decreased. In patients
with long anterior facial height (high MP-SN
angles), the m e a n distance f r o m the occlusal
plane to the inferior edge of the palate was 22.50
m m . This distance decreased to 19.6 m m for the
average g r o u p and 17.1 m m for the g r o u p with
125
short anterior facial height (low MP-SN angles).
This difference of 5.1 m m of dentoalveolar de-
v e l o p m e n t between the high angle and low an-
gle groups is of significance.
M a n d i b u l a r p o s t e r i o r alveolar d e v e l o p m e n t
similarly d e c r e a s e d with decreases in the
MP-SN angle b u t m u c h less dramatically t h a n
those f o u n d in the maxilla. M a n d i b u l a r h e i g h t
showed a m e a n of 31.2 m m for the l o n g ante-
rior face h e i g h t g r o u p , 28.2 for the average
126 Vaden and Pearson
Figure 7. An example showing a posterior-directed
growth pattern of the mandibular condyle.
group, a n d 28.3 for the s h o r t a n t e r i o r face
h e i g h t group.
The findings of the Issacson et a133 study were
confirmed in a study p e r f o r m e d by J a n s o n et
al. 34 These investigators f o u n d that all dentoal-
veolar heights were significantly greater in long
anterior facial height patients than in patients
with n o r m a l facial height. Also, in the short
lower anterior facial height, all dentoalveolar
heights were significantly shorter than in the
n o r m a l lower anterior facial height group.
T h e differences in dentoalveolar develop-
ment, most particularly in the maxilla, have a
significant impact on the anterior facial height
of the orthodontic patient. Moller and Inger-
val135 and T h i l a n d e r :~6 have postulated that ex-
cessive maxillary posterior dentoalveolar devel-
o p m e n t is associated with weaker masticatory
musculature in high-angle patients c o m p a r e d
with the strong musculature c o m m o n l y associ-
ated with short anterior facial height patients.
Enviornmental Role--Swallowing and
Tongue Posture
T h e role of tongue posture, swallowing, and
breathing are still subjects of debate, argument,
and study in orthodontics. Their respective im-
pact on the vertical dimension are in n e e d of
continued study and research.
Mouth breathing. T h e relationship between
m o u t h breathing, altered posture, and the de-
v e l o p m e n t of malocclusion is not as clear cut as
the theoretical o u t c o m e of shifting to oral respi-
ration m i g h t a p p e a r at first g l a n c e Y Recent ex-
perimental studies have only partially clarified
the situation. C u r r e n t e x p e r i m e n t a l data for the
relationship between malocclusion and m o u t h
breathing are derived f r o m studies of the nasal/
oral ratio in normal versus long-face c h i l d r e n Y
T h e data from the study show that both normal
and long-face children are likely to be predom-
inantly nasal breathers u n d e r laboratory condi-
tions. A minority of the long-face children had
less than 40% nasal breathing, whereas n o n e of
the normal children had such low nasal percent-
ages. W h e n adult long-face patients are exam-
ined, the findings are similar: the n u m b e r with
evidence of nasal obstruction is increased in
comparison to a n o r m a l population, but the
majority are not m o u t h breathers in the sense of
p r e d o m i n a n t l y oral respiration.
Airway problems, such as large adenoids, ton-
sils, or blocked ail~vays caused by septum devia-
tions, large conchae, or allergies are frequently
observed in high-angle patients and may affect
m a n d i b u l a r posture, allowing m o r e f r e e d o m for
posterior eruption. This hypothesis is s u p p o r t e d
by Linder-Aronson 39,4 who showed closing of
the m a n d i b u l a r plane angle and reduction in
the anterior face height after removal of ade-
noids and tonsillectomy.
It appears that research on respiration, up to
the present time, has resulted in two opposing
views: (1) total nasal obstruction is highly likely
to alter the pattern of growth and lead to mal-
occlusion in e x p e r i m e n t a l animals and humans,
and individuals with a high p e r c e n t a g e of oral
respiration are overrepresented in the long-face
population, but (2) the majority of individuals
with the long-lace pattern of deformity have no
evidence of nasal obstruction and must there-
fore have some o t h e r etiologic factor as the prin-
cipal cause.
In conclusion, it appears that m o u t h breath-
ing may contribute to the d e v e l o p m e n t of orth-
odontic p r o b l e m s but is difficult to indict as a
frequent etiologic agent. Clinically, most orth-
odontists refer m o u t h breathers to an otolaryn-
gologist tbr an evaluation. This p r o b l e m should
be carefully evaluated during the diagnosis of a
patient with excess vertical dimension.
 Diagnosis of the VerticalDimension
Swallowing and tongueposture. O n e viewpoint
holds that t o n g u e thrust swallowing is seen in
(1) y o u n g e r children with r e a s o n a b l y n o r m a l
occlusion in w h o m it r e p r e s e n t s only a transi-
tional stage in n o r m a l physiologic m a t u r a t i o n
a n d (2) in individuals who have displaced in-
cisors. In the latter, it is an a d a p t a t i o n to
the space b e t w e e n the teeth. O t h e r s a r g u e that
t o n g u e thrust swallowing simply has too
s h o r t a d u r a t i o n to have an i m p a c t o n t o o t h
position. Pressure by the t o n g u e against the
teeth d u r i n g a typical swallow lasts for a p p r o x -
imately 1 second. A typical individual swal-
lows a b o u t 800 times p e r day while awake b u t
has only a few swallows p e r h o u r while asleep.
T h e total p e r day, t h e r e f o r e , is usually u n d e r
1,000. O n e t h o u s a n d seconds of pressure, of
course, totals only a few minutes, n o t nearly
e n o u g h time, it is argued, to affect the equi-
librium. 41
Most clinicians believe that if a patient has a
forward resting posture of the tongue, the dura-
tion of this pressure, even if very light, could
affect tooth position, vertically or horizontally.
Tongue-tip protrusion during swallowing is
sometimes associated with a forward tongue pos-
ture.
During the diagnosis of the patient with a
vertical dimension problem, the clinician must
u n d e r s t a n d that condylar growth, sutural lower-
ing of the maxillary complex, dentoalveolar de-
velopment, dental eruption, and the patient's
oral e n v i r o n m e n t / h a b i t s are interrelated. T h e r e
is not generally a single causative factor that
predisposes the patient to too m u c h or too little
vertical d e v e l o p m e n t of lower facial height. To
simplify, one might conclude as a general rule,
that when vertical condylar growth exceeds
tooth eruption (alveolar development), forward
m a n d i b u l a r rotation occurs. T h e result is in-
creased posterior facial height a n d an increase
in the ratio of posterior facial height to ante-
rior facial height. Conversely, if dentoalveolar
growth and tooth eruption are greater than ver-
tical condylar growth, the resultant m a n d i b u l a r
change is backward rotation. T h e anterior facial
h e i g h t / p o s t e r i o r facial height ratio decreases. 42
Environmental factors can play a role, but the
role is, at times, difficult to assess and varies f r o m
patient to patient.
127
Diagnostic Considerations
Steep Excess Vertical Pattern:
The Backward Rotator
During differential diagnosis of the high-angle
patient, two questions must be asked. First,
where should the teeth be positioned? For the
patient with long anterior facial height, the man-
dibular anterior teeth are most often positioned
in a m o r e retracted posture over basal bone. Lip
p r o c m n b a n c y can be best resolved if the man-
dibular anterior teeth are upright. T h e a m o u n t
of uprighting that must be achieved is a matter
of (1) clinical preference and must be deter-
m i n e d during the t r e a t m e n t p l a n n i n g phase of
the t r e a t m e n t protocol or (2) the dictates of the
malocclusion. If indeed the facial profile of the
patient with excess vertical dimension is long, a
vertical reduction genioplasty can be effective
for facial esthetics. It is f u n d a m e n t a l for the
clinician to be able to visualize the posttreat-
m e n t positions of the m a n d i b u l a r anterior teeth
during t r e a t m e n t plan preparation. Secondly,
will extractions be necessary? For m a n y patients
with excessive lower anterior facial height, ex-
tractions may be necessary. T h e question of
which teeth should be extracted can be an-
swered only after a t h o r o u g h and accurate dif-
ferential diagnosis.
The Overdosed Forward Rotator
Patients with short anterior vertical facial height
have a unique set of problems that require dif-
ferent diagnostic considerations. The following
diagnostic guidelines should be considered
when a patient with this skeletal pattern is
treated without surgical intervention.
Mandibular incisors, if well aligned before
treatment, can be allowed to remain in their
p r e t r e a t m e n t position. Uprighting of mandibu-
lar incisors has an adverse impact on facial es-
thetics of the low-angle patient. However, the
m a n d i b u l a r incisors, if malaligned, should not
be proclined beyond their bony support for the
p u r p o s e of alignment.
Some overclosed forward rotator malocclu-
sions are characterized by a d e e p vertical over-
bite, maxillary incisor protrusion, a n d / o r crowd-
ing. Correction of the overbite for these patients
is best accomplished by intrusion and retraction
of the maxillary incisors.
128 Vaden and Pearson
Treatment Concerns
During the diagnosis of the vertical dimension
problem, the clinician must be attentive to the
force systems that are p l a n n e d for treatment and
understand that undesirable reactions to incor-
rectly applied fbrce systems are disastrous. Pos-
terior facial height must be carefully controlled
for the high-angle patient because an increase in
posterior facial height will result in an increase
in anterior facial height. 434~ An increase in an-
terior facial height of high-angle patients is ca-
lamitous.
An important mechanical tooth manipulation
that must be accomplished during the treatment
of the patient with excess vertical dimension is
prevention of extrusion of the mandibular pos-
terior teeth, assuming that the maxillary poste-
rior vertical dimension is controlled by intrusive
forces (ie, headgear or other methods). Extru-
sion in the molar areas will prevent successful
correction of the malocclusion with excess ver-
tical dimension and long lower anterior t:ace
height. It is important for the clinician to under-
stand these concepts during diagnosis and treat-
m e n t planning so that extraoral traction can be
planned to help control the vertical dimension
during treatment. There should be intrusive
forces to the posterior segments of both arches.
Additionally, Class II elastic wear can be one of
the most detrimental force applications that is
applied to a patient with long lower anterior
facial height. If Class II elastics are used indis-
criminately on the high-angle patient, the man-
dible drops down and back and increases the
sagittal discrepancy. Therefore, Class II elastic
use, or the absence of it, must be planned for
during diagnosis and treatment planning.
Pearson 4~ has published his results using ver-
tical pull chin cups and has provided evidence
that their use can create some effective skeletal
changes for the long-face patient. A thoughtful
diagnostician nmst consider the use of whatever
means is necessary to impact treatment and pre-
vent the lengthening of lower anterior facial
height during the course of treatment.
Summary
The orthodontic clinician must make a careful
differential diagnosis for each patient who seeks
his or her care. The diagnosis must analyze all
three c o m p o n e n t s of a malocclusion facial,
dental, and skeletal. Each c o m p o n e n t must be
carefully studied and u n d e r s t o o d so that (1) the
p r o p e r questions are asked and (2) the correct
diagnostic decisions are made to lead to an ef-
fective treatment plan.
Diagnosis of the vertical dimension is a con>
plex problem. Yet, it can be as simple as studying
a face and applying c o m m o n sense diagnostic
tools to ascertain the reason that the lower face
is too long or too short. The vertical dimension
has been a subject of study and debate since
orthodontics became a specialty. Researchers in
the field of vertical dimension diagnosis, includ-
ing Bjork, is Schudy, 27 Nielsen, 25 Isaacson, 29
Pearson, ~6 and others, have provided the spe-
cialty many useful guidelines and concepts that
can be used by every orthodontic clinician as
they diagnose a malocclusion that is complicated
by a vertical dimension discrepancy. Orthodon-
tists should continue to use the work of these
researchers and clinicians for a foundation as
more studies are u n d e r t a k e n that will yield more
knowledge so that diagnosis of the vertical di-
mension becomes less art and more science.
References
1. Angle EH: Malocclusion of the T e e t h a n d Fractures of
the Maxillae (ed 6). Philadelphia, PA, SS "v~qlite Co,
1900, p 15
2. Tweed el: Indications for the extraction of teeth in
orthodontic procedure. Am J O r t h o d 30:405-428, 1934
3. Peck H, Peck S: A concept of facial esthetics. Angle
O r t h o d 40:284-317, 1970
4. Burstone CJ: Lip posture a n d its significance in treat-
m e n t planning. A m J O r t h o d 53:262-284, 1967
5. Hulsey CM: An esthetic evaluation of lip-teeth relation-
ships present in the smile. A m J O r t h o d 57:132-144, 1970
6. Peck S, Peck L: Selected aspects o f the art a n d science of
facial esthetics. Semin O r t h o d 1:105-126, 1995
7. Merrifield LL: T h e profile line as an aid in critically
evaluating facial esthetics. A m J O r t h o d 52:804-821, 1966
8. Czarnecki ST, N a n d a R, Currier F: Perceptions o f a
balanced Facial profile. A m J Orthod, Dentnt~tcial Or-
thop 104:180-187, 1993
9. Ricketts RM: Divine proportions in facial esthetics. Clin
Plastic Surg 9:401-422, 1982
10. Steiner CC: Cephalometrics tor you a n d me. A m J
Ortfiod 39:729-755, 1953
11. Holdaway RA: A soft tissue analysis a n d its use in orth-
odontic t r e a t m e n t planning: Part I. Aau J O r t h o d 84:1-
28, 1983
12. Poulton DR: T h e influence of extraoral traction. A m J
O r t h o d 53:8-18, 1967
13. DeSmit A, D e r m a u t L: Soft-tissue profile preference.
A m J O r t h o d 86:67-73, 1984
 Diagnosis of the Vertical Dimension
14. Frakas LG: AnthropomeUT of the Head and Face in
Medicine. New York, NY, Elsevier Science, 1981
15. Frakas LG, Munro JR: Anthropometric Facial Propor-
tions in Medicine. Springfield, IL, Charles C. Thomas,
1987
16. Proffit WR: Diagnosis and Treatment Planning in Con-
tempormT Orthodontics. St. Louis, MO: Mosby, 2000
17. SaJv'er D, Proffit W, Ackerman J: Diagnosis and treat-
lnent planning in orthodontics fl'om orthodontics, in
Graber TM, Vanarsdall RL (eds): Current Principles and
Techniques (ed 3). St. Louis, MO, Mosby, 2000
18. Bjork A: Facial growth in man, studied with the aid of
metallic implants. Acta Odontol Scand 13:9-34, 1955
19. Bjork A: Variations in the growth pattern of the human
mandible: longitudinal cephalometric study by the im-
plant method..] Dent Res 400-411, 1963
20. Bjork A: Sntural growth of the upper face studied by the
implant method. Acta Odoutol Scand 24:109-129, 1966
21. Bjork A: The use of metallic implants in the study of"
facial growth in children, method and application. AlnJ
Phys Mlthropol 29:243-254, 1968
22. Skieller V: Cephalometric analysis in the treatment of
overbite. Rep Congr Eur Orthod Soc 147-I57, 1967
23. Bjork A, Skieller V: Facial development and tooth erup-
tion, an implant study at the age of puberty. Am .]
Orthod 621:339-383, 1972
24. Bjork A, Skieller V: Normal and abnormal growth of the
mandible: A synthesis of longitudinal cephalometric im-
plant studies over a period of twenty five years Eur
J Orthod 5:1-46, 1983
25. Neilsen i L: Vertical malocclusions: Etiology', develop-
ment, diagnosis and some aspects of treatment. Angle
Orthod 61:247-260, 1991
26. Pearson LE: Vertical control iu treaUnent of patients
having backward rotational growth tendencies. Angle
Orthod 48:130-140, 1978
27. Schudy FF: Vertical growth vs anteroposterior growth as
related to fimction and treatment. Angle Orthod 34:75-
93, 1964
28. B]ork A: Prediction of mandibular growth rotation. AmJ
Orthod 55:585-599, 1969
29. Isaacson RJ: The geometry of~acial growth and its effects
on the dental occlusion and facial form. J Charles H.
Tweed Int Found 9:21-38, 1981
30. Isaacson RJ, et al: Effects of rotational jaw growth on the
occlusion and profile Am J Orthod 3:276-286, 1977
31. Schudy FF: The rotation of the mandible resuhing fi'om
growth: Its implication in orthodontic treatment. Angle
Orthod 35:36-50, 1965
32. Proffit WM: The development of orthodontic problems,
in Proffitt WM, Fields HW (eds): Contemporaly Orth-
odontics. St. Louis, MO, Mosby, 2000, pp 102-106
129
33. IsaacsonJR, lsaacson RJ, Speidel TM, et al: Extreme varia-
tion in vertical facial growth and associated variation in
skeletal and dental relationships. Angle Orthod 41:219-
228, 1971
34. Janson G, Metaxas A, Woodside D: Variation in maxillaty
and mandibular molar and incisor vertical dimension in
12 year old subjects with excess, normal, and short lower
anterior face height. Am J Orthod Dentofacial Orthop
106:409-418, 1994
35. Moiler E: The chewing apparatus. Acta Physiol 69:571-
574, 1966
36. lngervall B, Thilander B: Relationship between f~tcial
morphology and activily of the mastecato D' muscles.
J Oral Rehap 1:131-147, 1974
37. Vig KWL: Nasal obstruction and thcial growth: the
strength of evidence for clinical assumptions. Am J
Orthod Dentofacial Orthop 113:603-611, 1998
38. Fields HW, Warren DW, Black K, et al: Relationship
between vertical dentofacial morphology and respira-
tion in adolescents. Am J Ortho Dentofacial Orthop
99:147-154, 1991
39. Linder-Aronson S: Effects ofadenoidectomy on the den-
tition and facial skeleton over a period of five years, in
Cook JT (ed): Transactions of the Third International
Orthodontic Congress. St Louis, MO, Mosby, 1975
40. Woodside DG, Linde~Aronson S, Lundstrom A, et al:
Mandibular and maxillmN growth after changed mode
of breathing. AmJ Orthod Dento~acial Orthop 100:1-18,
1991
41. Proffitt WR: The etiology of orthodontic problems. Con-
temporary Orthodontics (ed 3). St. Louis, MO: Mosby, p
136
42. Schudy FF: The rotation of the mandible resulting from
growth--Its implications in orthodontic treatment. The
Vertical Dimension of the Human Face. Houston, TX: D
Armstrong & Co, 1992, pp 151-179
43. Pearson LE, Pearson BL: Rapid maxillary expansion with
incisor intrusion: a study of vertical control. Am J
Orthod Dentofacial Orthop 115:576-582, 1999
44. Klontz HA: Facial balance and harmony: an attainable
objective tbr the patient with a high mandibnlar plane
angle. Am J Orthod Dentotacial Orthop 114:176-188,
1998
45. Vaden JL: Alternative uonsurgical strategies to treat
complex orthodontic problems. Semin Orthod 2:90-113,
1996
46. Pearson LE: The management of vertical dimension
problems in growing patients, from the enigma of the
vertical dimension. In McNamara J A J r (ed): Craniofa-
cial Growth Series 36, Center for Human Growth and
Development. Ann Arbor, MI, The Universi~ of Michi-
gan, 2000