position paper
J. Stomat. Occ. Med. (2009) 2: 147–159
DOI 10.1007/s12548-009-0027-7
Printed in Austria
© Springer-Verlag 2009
Vertical dimension of occlusion: the keys to decision
We may play with the VDO if we know some game’s rules
M. Rebibo1 , L. Darmouni2 , J. Jouvin3 , J. D. Orthlieb2
1
Nice, France
2
Faculté de Chirurgie-Dentaire de Marseille, Unité d’Occlusodontologie, Université de la Méditerranée, Marseille, France
3
Faculté de Chirurgie-Dentaire de Marseille, Unité de Prothèse, Université de la Méditerranée, Marseille, France
Received July 29, 2009; Accepted July 30; 2009
During an extensive prosthetic reconstruction, the choice of
the vertical dimension of occlusion (VDO) is frequently pres-
ented as the main point to obtain a success of treatment.
Probably, it is a sensible opinion to think that there is an
optimal adaptive space concerning the vertical dimension
(VD) rather than a magic point. The practitioner may play
with the VD, if a strict rotation around the hinge axis is utilized,
if the facial type is not worsened and if lip closure is kept in a
natural position. In case of temporomandibular osteoarthritis,
non progressive large changes of VD have to be avoided.
The decision making will be described in relation to
different factors, such as overjet, overbite, prosthetic space,
mandibular morphology, profile, vertical and horizontal skel-
etal type.
A decision-making table is proposed to visualize the trend
of these different factors.
Keywords: Vertical dimension, vertical dimension of occlu-
sion, decision making, prosthodontic, cephalometry
Introduction
For an extensive prosthetic reconstruction, the choice of the
vertical dimension of occlusion (VDO) is often referred to as
the central issue, the essential problem.
Paradoxically, many arguments are frequently used to
justify the changes of the VDO in both direction, increasing or
decreasing. Mechanical reasons (retention, prosthetic space,
and corono-root arm), aesthetic (profile and wrinkles), neu-
romuscular (resting posture and muscle strength) and even
articular (decompression) arguments are quite often used in
the debate on this particular subject.
Gaspard in 1985 concluded: “There is no accurate and
reproducible method for determining VD” [6]. Palla in 1995
[17], after a thorough literature’s review, confirms “Unfortu-
nately, despite our knowledge about the mechanisms that
Correspondence: Pr. Jean-Daniel Orthlieb, DDS, PhD, Faculté de
Chirurgie-Dentaire de Marseille, Unité d’Occlusodontologie, Université
de la Méditerranée, 27 bd Jean Moulin 13555 Marseille cedex 7, France.
E-mail: jean-daniel.orthlieb@univmed.fr
J. Stomat. Occ. Med. Ó Springer-Verlag
govern the different vertical dimensions and free way space,
their determination remains a process primarily based on
clinical experience of clinical practitioner”. At the time of
evidence-based dentistry, and despite 50 years of publication
on the subject, these findings place the practitioner still in a
situation with more or less hazardous decisions based on the
clinical experience.
Based on these facts, it seems to be quite important to
have proper tools in clinical decision making. How to verify
that the therapeutic VD will be in harmony with all the
anatomical and neuro-physiological determinants?
Furthermore, what are the objective criteria’s, which let
us determine to increase or decrease VD?
It is reasonable to believe that there is an optimal space
for the VDO and not a single point miraculous [19].The new
free way space and VD rest are the results of a phenomenon of
neuromuscular adaptation [7].
This area of adaptation of vertical closure is defined by an
upper limit, a lower limit and an amplitude, that remains to be
defined in terms of the potential for neuromuscular adapta-
tion to each and mechanical parameters to evaluate.
Having sought to identify relevant criteria, benchmarks
and insufficient unfounded beliefs, this article aims to propose
a method of comparing the critical reflection involved and
leading to a maintenance or modification of the quantized
VDO (in the sense of reduction or enlargement).
Myths or limits?
“The VDO could not be increased”
“Conserve the VDO corresponding to the ICP and don’t
increase it” [4]. The belief, that an increase in the vertical
dimension causes temporomandibular disorders (TMD), de-
rived from the following hypothesis: an elevation induces an
increase in the tonicity of elevator muscles, with a possible
onset of muscle pain, increased tooth mobility and finally
the intrusion of teeth. This ingression would generate a
decrease in VDO and a return to its initial value. Palla, on
the contrary, remarks, that this assumption, has not been
confirmed [17]:
Vertical dimension of occlusion: the keys to decision 3/2009 147
 position paper
Tab. 1: Definitions
VDO (vertical dimension of occlusion): height of the lower part of the face
measured between two markers (e.g. infra nasal point and Gnathion) where
the arches are in occlusion in maximal intercuspation position (ICP) [3].
VDR (vertical dimension of rest): height of the lower part of the face
measured between two markers, when the mandible is in rest posture or
physiological inocclusion [3].
FS (free way space): distance between the occlusal surfaces when maxillary
and mandibular jaw are in the rest posture. It is the difference between VDO
and VDR [3].
– A degree of relapse sometimes occurs after increasing
occlusal height, but it is not constant, and VDO is not the
original value when it is increased in one step of several
millimeters (e.g. in orthognathic surgery or in animal
experiments).
– This degree of relapse caused by bone remodeling and in-
gression of the teeth cannot only be connected to the
degree of increase and occurs especially in the early
months.
– An increased VDO does not appear to disrupt the chewing
function. It has been shown that the increase of VD results in
most cases a relaxation of closing muscles [20], which is
Fig. 1: (A, B) VDO decrease and Loss of posterior support of occlusion. (A) VDO decrease: Anterior mandibular rotation with a condylar rotation centre.
(B) Loss of posterior support of occlusion: Posterior mandibular rotation with an anterior rotation centre located on the more distal tooth
148 3/2009 Vertical dimension of occlusion: the keys to decision
found clinically on a daily practice with the wear of an
occlusal splint.
The opinion of the authors on relapses of VD is that the
control of functions (e.g. Tongue interposition, clenching)
could be a more important factor of avoiding a relapse than
the proper initial variation of VDO:
Increase the VDO: A skeletal open bite type is not a
complete obstacle to increase VDO, but the relaxed closed
lip posture could represent a limit. In case of a relapse with the
result of a decreased lower facial height few years after
treatment, there is at least the strong possibility to link this
relapse to an uncontrolled behavioural factor (e.g. dental
intrusions due to clenching or bruxism)?
Decrease the VDO: In some anterior open bite cases, a
decrease of the VDO must be accompanied by a strong
coaching of functional reeducation of nasal breathing, rest
posture of the tongue and swallowing.
“VDO could not be reduced” or the confusion
between loss of VD and subsequent loss
of occlusal posterior support
On the topic of reducing the VDO, we find contradictory
and unjustified opinions as: “Any grinding cusps inevitably
Ó Springer-Verlag J. Stomat. Occ. Med.
 position paper

A B

Fig. 2: Loss of occlusal posterior support probably without loss of vertical dimension of occlusion (A: ICP right lateral view, B: ICP left lateral view)

A B C

D E

Fig. 3: (A–E) Loss of vertical dimension of occlusion: Loss of occlusal posterior support combined with skeletal disharmony (A: Protrusion, B: ICP
frontal view, C: ICP right lateral view, D: ICP left lateral view, E: Sagittal teleradiography in ICP)

causes a reduction in VD” [6], “Few cases warrant a reduction
in VD”; “There is no apparent problem associated with the
decrease in VD” [4]. This latter view seems to be confirmed by
Magnusson [9].
If, in the past, it has often stated that the TMD are
correlated with loss of VD, probably due to the frequent
confusion between loss of VDO and subsequent loss of occlu-
sal posterior support [14].
From a geometrical and mechanical point of view, a
decrease of the VD is completely different to the loss of
posterior occlusal support. The VDO corresponds to the
limit of rotation of mandibular elevation, which means
that its variations corresponds to the situation of the
“vertical occlusal stop” of rotation of mandibular elevation
which means that the variations of VDO are carried out
around the mandibular hinge axis, defining an angle of
rotation.
It is thus aberrant to speak about posterior vertical
dimension and anterior vertical dimension. Perhaps the terms
posterior and anterior “dental space” or “available prosthetic
height” should be used instead. There is only one VD for the
mandible; variations of this VD are related to angular rotation
in regards to the mandibular hinge axis.
On the contrary, the loss of posterior occlusal support
corresponds to a posterior mandibular rotation around an
anterior dental point of support (centre of rotation), this
situation could be critical for the TMJ [24].
“Dental abrasion would mean loss of VDO”
In fact, generally dental abrasion does not mean loss of VDO.
Since Niswonger in 1938 [11], we should know, that the
presence of abraded teeth does not mean that the VD is
Categories of loss of vertical dimension of occlusion:
– Missing teeth combined with skeletal disharmony
– Missing teeth combined with teeth abrasions
– Missing teeth combined with abrasions and teeth migrations
– Iatrogenic procedure

J. Stomat. Occ. Med. Ó Springer-Verlag Vertical dimension of occlusion: the keys to decision 3/2009 149
 position paper

A B C

Fig. 4: (A–C) Anterior teeth abrasion: probably no loss of VDO (A: occlusal view, B: ICP frontal view, C: Sagittal teleradiography in ICP)

A B C

D E F

Fig. 5: (A–C) Missing teeth combined with teeth migrations (A: ICP right lateral view, B: ICP frontal view, C: ICP left lateral view, D: maxillar arch,
E: mandibular arch, F: Sagittal teleradiography in ICP)

A B C

D E F

Fig. 6: (A–C) Loss of vertical dimension of occlusion: Loss of occlusal posterior support combined with teeth abrasions (A: ICP right lateral view, B: ICP
frontal view, C: ICP left lateral view, D: occlusal view, E: mounting cast in centric relation, F: Sagittal teleradiography to test an increased VDO)

150 3/2009 Vertical dimension of occlusion: the keys to decision Ó Springer-Verlag J. Stomat. Occ. Med.
 position paper

Fig. 7: Osteoathrosis: sagittal MRI in occlusion and open mouth: the remodeling of articular surfaces could decrease the capacity of the joint
adaptation

systematically reduced, a compensatory egress, especially in “Posture of rest and free way space would be stable
the anterior teeth, is very frequently observed. clinical references”
The presence of anterior dental migration, with re-
Rivera-Morales [19], Rugh and Drago [20], amongst many
cent diastemas, associated with a subsequent loss of
others, have reported the lack of reproducibility of the
posterior support seems to be a more obvious clinical
vertical dimension of rest (VDR) evaluations (electromyo-
situation [12].
graphic or clinical), the large variability of the free way
space and its adaptability to VDO variations. From a
hypothetical clinical measurement of the inter-occlusal
Tab. 2: Correspondence’s table: changes free way space, what is the basis to evaluate the level of
of VDO in mm the VDO?
Molar Variations in mm
Incisor Anterior pin Phonetic tests are clinical stable references

5.3 10 15.6 Although Silverman [21] thought, minimum vertical phonetic

space as immutable, but clinical experiences generaly found
4.7 9 14.1 that there is a large capacity of adaptation in this area.
4.2 8 12.5
3.7 7 10.9
3.2 6 9.4
2.6 5 7.8
2.1 4 6.3
1.6 3 4.7
1.3 2.5 3.9
1.1 2 3.1
0.8 1.5 2.3
0.5 1 1.6
0.3 0.5 0.8
0.0 0 0.0

Calculation of correspondence between variation of VDO at the second molar

(dm), incisior (di) and variation at incisal pin of articulator (a)
i: distance in horizontal projection between the condyle and incisor (80 mm
average value)
m: distance in horizontal projection between the condyle and second molar
(42 mm average value)
t: distance in horizontal projection between the condyle and incisal table Fig. 8: Rule of “the thirds”: for a same vertical variation, molar height,
(125 mm on SAM Ariculator) incisal and anterior pin are proportional. The “rule of third” stated that for
a ¼ (di
t)/i a ¼ (dm
t)/m 3 mm increase at incisal pin. We obtain a 2 mm increase on incisors and
1 mm increase on molars

J. Stomat. Occ. Med. Ó Springer-Verlag Vertical dimension of occlusion: the keys to decision 3/2009 151
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Fig. 9: (A, B) VDO and dento-skeletal compensation: A VDO increase leads to an overjet increase and an overbite decrease. It makes a Class II worse
(A) and a Class III compensation (B)

Using “wheezing whistling (sibilant) sound or “S” In conclusion, presumably, we have a large capacity of adaptation to changing
would be the most reliable method, provided that the of VDO, but we have to keep in mind that this variation:
patient is wearing the prosthesis approximately 1 week – is strictly in rotation around the hinge axis,
(at least 1 day). – does not worsen a vertical skeletal type already out of standard,
If the patient has phonetic difficulties after 4 weeks, an – preserve the labial contact.
equilibration is indicated by placing a marker on the maxillary We have to avoid important and abrupt variations in the presence of TMJ
osteoarthrosis and also amongst patients having a weak neuromuscular
teeth, whilst the patient articulates “66” “[23]”, or pronounce
adaptation like elderly persons or patients with systemic or central neuro-
sounds such as S, Che, Z and F [2].
muscular disorders.
But the above-mentioned tests are meaningless, in
case the anterior dental arrangement is disturbed! Thus,
these phonetic tests are only “a posteriori” verification, i.e. Tab. 3: Simple rules about variations of vertical
after the fitting of provisional dental elements truly in dimension of occlusion
function.
VDO Decrease Conserve Increase
Small overbite Osteoarthrosis Important overbite
Changes in VDO could affect TMJ
Important overjet Elderly patient Small overjet
Strict variation of VDO causes a mandibular rotation around the
hinge axis. This rotational condylar movement is completely Long face Short face
physiological and induces a very limited intra-capsular move- Class II Class III
ment: An increase by 1 mm on the incisors level causes a condyle
Skeletal openbite Skeletal deepbite
rotation of approximately 1, which is equivalent to a shift of the
condylo-disc interface of 0.1 mm. So, with healthy TMJ, increase Large prosthetic Small prosthetic
or decrease in VDO will not cause any joint changes. height available height

152 3/2009 Vertical dimension of occlusion: the keys to decision Ó Springer-Verlag J. Stomat. Occ. Med.
 position paper

Only in the case of severe TMJ osteoarthrosis
(flat condyle), a variation of the VDO (greater than 3 mm
on incisor) could cause a situation of constraint in the
TMJ [22].
Vertical dimension of occlusion: the decision’s
criteria
The classical presence of an inter-occlusal space in resting
posture and the lack of contact between the dental arches

Clinical case N°1: VDO Increase

A B

C D E

F G H

Therapeutic Vertical Dimension of Occlusion : keys of decision T.MJ Muscles

I
Prosthetic height available Anterior occlusal relation Typology Decision Matches
Incisal Incisal
Posterior Anterior Overjet Overbite Cephalometry Aesthetic +3 mm pin
Initial level level
Insufficient Insufficient Insufficient Insufficient Insufficient VDO Insufficient VDO
situation = = = = = =
Excessive Excessive Excessive VDO Excessive VDO –5 10 16,0
Excessive Excessive
9 14,0
–4 8 12,5
–3 7 11,0
–5 –5 –5 –5 –5 –5 –2 6 9,5
–4 –4 –4 –4 –4 –4 5 8,0
–3 –3 –3 –3 –3 –3 –1
4 6,0
Desirable –2 –2 –2 –2 –2 –2 0 3 4,5
–1 –1 –1 –1 –1 –1 +1 2,5 4,0
Correction 0 0 0 0 0 0
2 3,0
+1 +1 +1 +1 +1 +1 +2
+2 +2 +2 +2 +2 +2 1,5 2,5
of VDO +3
1
+3 +3 +3 +3 +3 +3 1,5
+4 +4 +4 +4 +4 +4 +4 0,5 1,0
+5 +5 +5 +5 +5 +5 +5 0 0,0

All changes in VDO are quantified in millimeters at incisal level

Fig. 10: (continued)

J. Stomat. Occ. Med. Ó Springer-Verlag Vertical dimension of occlusion: the keys to decision 3/2009 153
 position paper
J K
M N
Fig. 10: (A) Extra oral view. (B) Initial Sagittal telepradiography. (C–E) Initial ICP views. (F–H) Initial casts in centric relation. (I) Decision algorithm. The
patient does not present a gum smile; surgical coronorary elongation is not considered. DECISION: VDO needs a 3 mm increase, in order to obtain
a sufficient anterior prosthetic height. VDO increase value is limited here by excessive overjet and posterior prothetic height. (J) Corrected VDO on
cephalometry. (K, L) Wax-up. (M) Temporary teeth. (N) Final prosthesis
during phonation are indicators for a VDO treatment.
But, it seems, that they are usually acquired by spontane-
ous adaptation of the patient. These muscular references
appear too much unreliable. From our actual opinion,
the objective criteria, which will influence really our deci-
sion, are:
. Prosthetic height available
. Anterior occlusal relation: Overjet and overbite.
After this two essential criteria’s, we have to control in the
next step, if they are in harmony with:
. Skeletal typology and morphology of the mandible
. TMJ and neuromuscular coordination
. Aesthetic and facial heights.
Prosthetic height available
Retention is a mechanical factor influencing directly the
prognosis of our fixed restorations, it is therefore impera-
tive. We can consider that the height of an abutment for
crowns should be greater than 4 mm. By contrast, crown
height does not exceed the height of the root anchorage.
The crown height is also depending from the occlusal
plane.
Finally, once VDO and occlusion plan are designed, the
prosthetic height available can be increased at the expense of
the periodontium by surgical coronary elongation.
The choice will be between sufficient retention and
favourable crown-root ratio.
To facilitate the analysis, we have to discern the posterior
prosthetic height and the anterior prosthetic height.
The graduated anterior pin of articulator allows the
necessary quantitative assessment, taking into account
the variations related to the proportional variation angle of
154 3/2009 Vertical dimension of occlusion: the keys to decision
L
the mandible. This calculation is generally allowed by the rule
of thirds, or by trigonometric calculation.
Overjet and overbite
Overbite is an average of 3–4 mm and overjet average is
2–3 mm in the current populations [12]. Obtaining or main-
taining functional anterior contact and anterior cinematic
control is one of the main objectives of the prosthetic treat-
ment. Changes in the VDO directly influence occlusal anterior
relations, so the anterior objectives will dominate the choice of
VDO.
Increase VDO reduces anterior overbite and increases the
overjet. So we could use an increase of the VDO in case of
excessive overbite or insufficient overjet.
Conversely a decrease VDO leads to an increase of the
overbite and to a decrease of the overjet. So, it is interesting to
decrease VDO in case of excessive overjet or insufficient
overbite.
Skeletal typology and mandibular morphology
Classical cephalometric analysis can identify skeletal verti-
cal type of patient (hyper-, hypo- or normo-divergent) and
the sagittal skeletal type (skeletal Class I, II or III). It seems
logical that VDO generated by the therapeutic treatment
does not worse a dysgnathy. But tends rather to compen-
sate it [1].
By the way of the mandibular rotation around the con-
dyles, an increase in VDO aggravates skeletal class II and
compensates skeletal Class III. In contrast, a decrease of VDO
aggravates skeletal class III and compensates some Class II
skeletal.
Ó Springer-Verlag J. Stomat. Occ. Med.
 position paper

Edwards showed the great variability generated by using In addition, a statistical study on 450 sagittal cephalo-
as a reference for simple angle average of the angle Anterior grams showed correlations between the height of the lower
Nasal Spine point-Xi point-suprapogonion point (ANS-Xi- facial height and mandibular morphology measured by the
pm) [5]. gonial angle and mandibular arch angle. A correlation table

Clinical case n°2 : VDO light increase

A B C

D E F

Therapeutic Vertical Dimension of Occlusion : keys of decision T.MJ Muscles

H
Prosthetic height available Anterior occlusal relation Typology Decision Matches
Incisal Incisal
Posterior Anterior Overjet Overbite Cephalometry Aesthetic +2 mm pin
Initial level level
Insufficient Insufficient Insufficient Insufficient Insufficient VDO Insufficient VDO
situation = = = = = =
Excessive Excessive Excessive VDO Excessive VDO –5 10 16,0
Excessive Excessive
9 14,0
–4 8 12,5
–3 7 11,0
–5 –5 –5 –5 –5 –5 –2 6 9,5
–4 –4 –4 –4 –4 –4 5 8,0
–3 –3 –3 –3 –3 –3 –1
4 6,0
Desirable –2 –2 –2 –2 –2 –2 0 3 4,5
–1 –1 –1 –1 –1 –1
0 0 0 0 0 0
+1 2,5 4,0
Correction 2 3,0
+1 +1 +1 +1 +1 +1 +2
+2 +2 +2 +2 +2 +2 +3 1,5 2,5
of VDO +3 +3 +3 +3 +3 +3 1 1,5
+4 +4 +4 +4 +4 +4 +4 0,5 1,0
+5 +5 +5 +5 +5 +5 +5 0 0,0

All changes in VDO are quantified in millimeters at incisal level

Fig. 11: (continued)

J. Stomat. Occ. Med. Ó Springer-Verlag Vertical dimension of occlusion: the keys to decision 3/2009 155
 position paper
I J
Fig. 11: (A–C) Initial ICP view. (D–F) Initial casts view in centric relation. (G) Initial sagittal telepradiography. (H) Decision algorithm. The patient has a
skeletal openbyte. The insufficient anterior prosthetic height available, associated to the large overjet limit the VDO increase. DECISION: þ2 mm of VDO
and orthodontic treatment to correct the overjet, followed by prosthesis and mandibular incisor coronoplasty. (I) Simple orthodontic treatment. (J) Post
orthodontic treatment sagittal telepradiography. (K) Prepared teeth. (L) Final prosthesis
based on measurements of these angles, allows us to offer
VDO in harmony with the bony structures [16]. However, this
more precise approach does not allow us to define the VDO
with a sufficient precision (millimeter) because of the indi-
vidual variability. The cephalometric analysis does not give
precisely the ideal value of VDO. But it shows the direction of
the treatment.
TMJ and neuro-muscular coordination
A careful clinical examination (intra-auricular palpation
showing difficulties of rotation. auscultation of crepitations)
associated with a careful anamnesis and the observation of a
panoramic radiography (flat condyle) is used most often to
discern a healthy subject to a TMJ advanced osteoarthrosic
phenomena.
In this case, it is advisable to avoid significant abrupt
variation of VDO as well as in patients, suspected to have a low
potential for neuromuscular adaptation (such as elderly
patient).
In other cases under physiological situation, we will have
a green light to changes of VDO as we need from mechanical
or aesthetic point of view.
Aesthetic and facial heights
The therapeutic VDO targets a harmonious facial appearance
with a pleasant appearance of the lower facial height in
occlusion.
Except for the subjective visual assessment, anthropo-
metric measurements from photography allow quantifica-
tion and comparison to previous documents. Ravon [18]
following McGee [8] researched measurements of the height
156 3/2009 Vertical dimension of occlusion: the keys to decision
K
of the lower face in correlation to the distances Glabella-
Nasion, Nasion-Gnation, line bi-pupillary-cleft lip, inter
pupillary. This is to have an approximate value of VDO,
which seems more valid than the proportional analysis too
variable as the ratio of Wilie between middle and lower facial
height [15].
But the impact of a vertical variation of 1 or 2 mm is very
low in regards to facial aesthetics, but is very important from
mechanical or occlusal aspects.
The rational decision
The practitioner can play with the VDO in the area of adapta-
tion according to the biological, mechanical or aesthetic
specific requirements.
The study on articulator is irreplaceable to assess directly
the influence of variations of VDO on the posterior and anterior
prosthetic heights available and back, and on the anterior
occlusal relations (overbite and overjet).
The previous decision criteria do not play an equal role
from the decision point of view.
Some of them are more determinants.
A rational of decision can be proposed in 5 phases:
1 – Anterior and posterior heights available will be evaluated
taking into account the mechanic requirements (stability
and resistance).
2 – The importance of creating or maintaining anterior oc-
clusal contacts gives a principal role to the value of
anterior overjet and overbite.
3 – Then the skeletal typology and mandibular morphology
must be observed and understood.
Ó Springer-Verlag J. Stomat. Occ. Med.
 position paper

4 – Next . . . the repercussions on the aesthetic will be taken in A calculation table provides, for the same angular varia-
count. tion of VDO, the correspondences in millimeters at the in-
5 – And finally checks the musculo-articular green light to give cisors and the upper incisor of articulation (for an individual of
the timing of the VDO variation (in one step or average size).
progressively).
Clinical cases
The proposed algorithm allows the variation of VDO Three clinical cases illustrate decision criteria and final results.
treatment to consider in relation to each criterion. The in- Case 1: See Fig. 10.
volvement of the VDO was quantified in millimeters at the Case 2: See Fig. 11.
incisors. Case 3: See Fig. 12.

Clinical case n°3 : VDO Decrease

B C

D E F

Therapeutic Vertical Dimension of Occlusion : keys of decision T.MJ Muscles

G
Prosthetic height available Anterior occlusal relation Typology Decision Matches
Incisal Incisal
Posterior Anterior Overjet Overbite Cephalometry Aesthetic –3 mm pin
Initial Insufficient
level level
Insufficient Insufficient Insufficient Insufficient VDO Insufficient VDO
situation = = = = = =
Excessive Excessive Excessive Excessive VDO Excessive VDO –5 10 16,0
Excessive
9 14,0
–4
8 12,5
–3 7 11,0
–5 –5 –5 –5 –5 –5 –2 6 9,5
–4 –4 –4 –4 –4 –4 5 8,0
–3 –3 –3 –3 –3 –3 –1
4 6,0
Desirable –2 –2 –2 –2 –2 –2 0 3 4,5
–1 –1 –1 –1 –1 –1
+1 2,5 4,0
Correction 0 0 0 0 0 0
2 3,0
+1 +1 +1 +1 +1 +1 +2
+2 +2 +2 +2 +2 +2 1,5 2,5
of VDO +3
1 1,5
+3 +3 +3 +3 +3 +3
+4 +4 +4 +4 +4 +4 +4 0,5 1,0
+5 +5 +5 +5 +5 +5 +5 0 0,0

All changes in VDO are quantified in millimeters at incisal level

Fig. 12: (continued)

J. Stomat. Occ. Med. Ó Springer-Verlag Vertical dimension of occlusion: the keys to decision 3/2009 157
 position paper

H I J

K L M

N O P

Q R

Fig. 12: (A) Extra oral view. (B) Panoramic radiography. (C) Sagittal teleradiography. (D, E) Initial dental arches. (F) initial ICP. (G) Decision algorithm.
Principal objective: to obtain anterior contacts in centric relation. Orthodontic treatment was rejected. THERAPEUTICAL HYPOTHESIS: An avulsion of
the wisdom teeth and an occlusal equilibration by selective tooth grinding will permit a 3-mm VDO decrease. A simulation of the treatment must be
realized on articulator. (H–K) Occlusal analysis in centric relation, the value of the anterior pin is noted. (L–O) Evaluation of the feasibility of the occlusal
equilibration. (P–R) Final result one year later

Conclusions
Practitioner can play with the VDO but have to be aware of the
rules, e.g. optimize occlusal relationships earlier, the mechan-
ical aspects of retention and the crown-root offset, slightly
skeletal types and promote the aesthetic and the potential
benefits of adaptation, when they exist.
It is by combining these different criteria that best
define the VDO to consider to be therapeutic. The imple-
mentation of this project through a provisional restoration
will validate particularly in relation to the muscular
response.
Except for some specific patient (osteoarthrosis or elderly
patients), our clinical experience leads us to make changes in
VDO in only one step, a phased approach does not appear to
affect prognosis and severely complicates the protocols.
Probably, clinical research from a position of comfort by
successive approach, is not a justification of a physiological
balance vertically, but much more a sign of harmony occlusal
functions centreing, fitting and guiding. On the contrary, a
discomfort does not necessarily implicates a vertical problem,
but generally an occlusal disorder, such as mandibular devia-
tion, disharmony of the posterior occlusal support or occlusal
interferences.
Conflict of interest
The authors declare that there is no conflict of interest.

158 3/2009 Vertical dimension of occlusion: the keys to decision Ó Springer-Verlag J. Stomat. Occ. Med.

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