CLINICAL RESEARCH

A proposed linear skeletal distance to predict occlusal vertical

dimension: A cephalometric study
Mohammed Nasser Alhajj, BDS, MSca and Ammar A. Daer, BDS, MScb

Loss of the vertical dimension of ABSTRACT

the lower third of the face as a Statement of problem. Establishing a correct occlusal vertical dimension is considered one of the
result of tooth loss can dramat- most important aspects of facial esthetics for patients in need of oral rehabilitation.
ically lead to changes of the hard
Purpose. The purpose of this retrospective study was to evaluate the use of a proposed linear
and soft tissue of the face and
skeletal distance to predict the appropriate occlusal vertical dimension.
on the jaw complex. The
essential role of complete den- Material and methods. A total of 93 digital cephalometric radiographs were collected in Joint
ture prosthodontics is to restore Photographic Experts Group (JPEG) format (51 men, 42 women) from the archive of the ortho-
dontics department at the Faculty of Dentistry, Sana’a University, Yemen. The distance from nasion
facial appearance, function, and
(Na) to sella (Se) and the distance from anterior nasal spine (ANS) to menton (Me) were measured
masticatory ability and to on the cephalometric radiographs, using ImageJ software. The data were compared statistically
maintain the patient’s oral using the Pearson correlation coefficient, regression analysis, and paired- and 1-sample t tests
and general health. Different (a=.05).
methods are used for measuring Results. The findings of the study revealed a significant positive correlation (P<.001) between the
the occlusal vertical dimension measured distances in men, with minimum difference between the variables. However, no signif-
(OVD) during complete denture icant correlation (P=.058) was found for women.
treatment, including the physi-
Conclusions. The distance from Na to Se can be used as an additional aid in estimating the occlusal
ologic rest position, the swal- vertical dimension in men for the study population. (J Prosthet Dent 2017;-:---)
1,2
lowing technique, the closest
speaking space method,3 finger
length,4 and various facial reference points.5-8 These tech- use after OVD loss16; registering the physiologic rest
niques are quite effective but still objective and arbitrary. A position of the mandible17,18; cephalometric evaluation of
more accurate technique, therefore, is required to gain more OVD in patients with edentulism during complete den-
precise and reproducible measurements of the OVD.9-12 ture treatment19,20; and assessment of a planned exten-
The use of cephalometric radiographs has been sug- sion of the OVD in patients with edentulism presenting
gested as a useful method of predicting the OVD by with existing complete dentures.21-23
determining the correlation between certain craniofacial In the absence of pre-extraction records, it is difficult
components (points, lines, and/or angles), which remain to directly measure or predict the required space for
relatively unchanged after tooth loss.13,14 The use of dentures between the edentulous jaws. Therefore, using
cephalometric radiographs in evaluating and assessing another measured distance as an alternative is helpful. To
the OVD can be divided into their use in dentate patients correlate the proposed or alternative distance with the
to determine certain craniofacial indicators correlated corresponding OVD these tests should be performed in
with the OVD for later use of these indicators14,15; pre- individuals with preserved and normal OVD. The alter-
extraction cephalograms kept as a reference for later native distance should be practical, time-saving,

a
Postgraduate student, Department of Prosthodontics, Faculty of Dentistry, Thamar University, Dhamar, Yemen.
b
Postgraduate student, Department of Orthodontics, Faculty of Dentistry, Sana’a University, Sana’a, Yemen.

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Clinical Implications
The distance measured from nasion to sella in a
cephalometric radiograph is significantly correlated
with occlusal vertical dimension based on the
Se Na
distance from the anterior nasal spine to the
menton. This distance can be used as a helpful and
reliable landmark to determine the OVD in patients
who have lost this vertical component.

straightforward, and measured directly without the use of

any other additional measurements, instruments, or
ANS
equations. Moreover, the difference between the
measured and predicted distances should be minimal.
The cephalometric points nasion (Na) and sella (Se)
are well-known landmarks that can be easily identified
on a radiograph. Therefore, the purpose of this study was
to evaluate the correlation between a proposed skeletal
distance measured from Na to Se and occlusal vertical
dimension measured from the anterior nasal spine (ANS)
to inferior border of the chin (menton; Me) on cephalo-
metric radiographs. Me

MATERIAL AND METHODS Figure 1. Cephalometric landmarks used. ANS, anterior nasal spine. Me,
menton. Na, nasion. Se, sella.
This study was conducted at the Faculty of Dentistry, Sana’a
University in Sana’a City, Yemen, from January 2015 to May
2015. An ethical clearance letter was obtained from the
frontonasal suture in the median plane, to the Se, the point
ethical committee at the Faculty of Dentistry. The available
representing the midpoint of the pituitary fossa, was
digital cephalometric radiographs archived in the ortho-
measured and recorded. The second distance representing
dontics department at the Faculty of Dentistry, Sana’a
the OVD was measured from the ANS, the tip of the bony
University, comprised the study population. These radio-
anterior nasal spine in the median plane, to the Me, the
graphs were obtained during previous research conducted
lowest midline point on the mandibular symphysis (Fig. 1).
among dental students to describe the skeletal and soft
For an intrarater test of reliability, distances were measured
tissue norms of Yemeni adults.24 Records that fulfilled the
twice on 16 cephalograms at 1-month intervals. Data were
inclusion criteria of normal occlusion with a balanced facial
analyzed using the intraclass correlation coefficient (ICC)
profile (class I molar relationship with alignment of the
test. The results revealed a significant level of reliability and
teeth and harmonious facial features), complete permanent
reproducibility (ICC=0.965, P<.001) (Table 1).
dentition (except third molars), suitable film quality (all
For descriptive analysis, the mean ±standard deviation
landmarks clearly visible), and vertical and horizontal
(SDs) were determined. One sample t test was used to test
overlap of the incisors within the normal range of 2 to 4 mm
whether the means of the Na-Se distance differed from
were selected. The exclusion criteria were craniofacial de-
the value of the OVD (ANS-Me). To measure the differ-
formities, class II or III malocclusion, previous or current
ences between the means, a paired sample t test was used.
orthodontic treatment, history of previous orthognathic
For correlation, the Pearson correlation coefficient was
surgery, presence of extensive dental restorations (wearing
used. Analysis of the relationship between the variables
dentures and/or multiple crowns or fixed prostheses), and
was also performed using linear regression. Variations
unclear cephalometric radiographs. A total of 93 cephalo-
between men and women were tested using the inde-
metric radiographs were collected in digital Joint Photo-
pendent t test. All tests were made with statistical soft-
graphic Experts Group (JPEG) format.
ware (IBM SPSS Statistics v22; IBM Corp) (a=.05).
The distances on the digital radiographs were measured
using software (ImageJ v1.51; National Institutes of Health).
RESULTS
All distances were spatially calibrated relative to the known
distance of a millimeter ruler attached to each radiograph. The study sample consisted of 93 dental students (51
The distance from the Na, the most anterior point of the men, 42 women) ranging from 18 to 25 years of age. As

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Table 1. ICC for reliability (n=16) Table 2. Descriptive statistics of mean ±SD for study sample
95% CI Sex Variable Minimum Maximum Mean ±SD
Sex ICC Lower Upper P All (93) Na_Se 57.22 77.99 66.08 3.92
All 0.965 0.926 0.987 <.001 ANS_Me 52.07 78.32 64.22 5.35
(Na-Se) 1 and (Na-Se) 2 0.995 0.985 0.998 <.001 Men (51) Na_Se 57.22 77.99 67.80 4.13
(ANS-Me) 2 and (ANS-Me) 2 0.989 0.969 0.996 <.001 ANS_Me 52.07 78.32 66.24 5.36

ANS, anterior nasal spine; ICC, intraclass correlation coefficient; Me, menton; Na, nasion;
Women (42) Na_Se 58.52 70.05 64.00 2.34
Se, sella. ANS_Me 52.38 71.89 61.76 4.23

ANS, anterior nasal spine; Me, menton; Na, nasion; Se, sella.

shown in Table 2, the distance from Na to Se for the

whole study sample was higher than the distance from Table 3. Paired samples test for differences between study variables
the ANS to the Me (OVD representative). For male Paired Differences
students, the Na-Se distance was 67.80 ±4.13 mm, and 95% CI
the ANS-Me distance was 66.24 ±5.36 mm. However, in Sex Variable Mean ±SD Lower Upper P
women, the Na-Se distance was 64.00 ±2.34 mm, and All (Na_Se) e (ANS_Me) 1.87 4.47 0.95 2.79 .001
the ANS-Me distance was 61.76 ±4.23 mm. The Pearson Men (Na_Se) e (ANS_Me) 1.56 4.71 0.24 2.89 .022

correlation coefficient test results revealed a significant Women (Na_Se) e (ANS_Me) 2.23 4.19 0.93 3.54 .001

correlation between the measured distances for the ANS, anterior nasal spine; Me, menton; Na, nasion; Se, sella.

whole sample (r=0.572; P=.001). For men, the correlation

was also significant (r=0.533; P=.001). However, no sig- Table 4. One-sample test for dispersion between study variables
nificant correlation was found in women (r=0.295; Test Value (ANS-Me)=64.23
P=.058). Using the paired samples t test (Table 3), we 95% CI
found a statistically significant difference between the Sex Variable t df P Mean Difference Lower Upper
measured distances for all groups (1.87 ±4.47; P=.001) for All N_Se 4.56 92 <.001 1.85 1.05 2.66
the whole sample, 1.56 ±4.71 with P=.022 for men and Men N_Se 2.70 50 .010 1.56 0.40 2.72
2.23 ±4.19 with P=.001 for women. The regression Women N_Se 6.19 41 <.001 2.24 1.51 2.97
analysis test results revealed a significant relationship ANS, anterior nasal spine; Me, menton; Na, nasion; Se, sella.
between the measured distances in men (model sum-
mary: R=0.533, R2=0.284, P<.001). However, a nonsig-
nificant relationship was found in women (model from the ANS to the Me by measuring another linear
summary: R=0.295, R2=0.087, P=.058). The 1-sample t dimension based on the distance from Na to Se, was
test was used to determine the dispersion of the Na-Se evaluated. The correlation between the skeletal Na-Se
values from the OVD (ANS-Me) value (Table 4). Sig- distance and that of the OVD (ANS-Me) was tested
nificant dispersion (P<.05) was detected between the among men and women and among the whole sample.
measured distances for the study sample as a whole and The findings of this study revealed a value of 66.08 ±3.92
for men and women separately. The t value of mm for the Na-Se distance and 64.22 ±5.35 mm for the
the measured distances was highest for women [t (41)= ANS-Me distance in the whole sample. However, these
6.19] followed by the value for the whole study sample values were significantly different when related to sex,
[t (92)=4.56], and lowest for men [t (50)=2.70]. The with higher values in men than in women. The variations
results of the independent t test indicated significant between both sexes were also found in previous studies
differences (P<.05) between sexes regarding the study conducted in Yemeni,24 Iraqi,25,26 and Moroccan27
variables. individuals.
In the present study, the correlation coefficient test
revealed a significant correlation between the 2 variables
DISCUSSION
for all participants as a whole and for men in particular.
Establishing an appropriate lower facial height in patients However, no significant correlation was found between
who require prosthetic treatment is a crucial step. Many the study variables in women (P>.05). This difference
clinical methods have been described for the determina- might have been related to sex-specific changes in the
tion of OVD, but no single method has proved superior. cranial skeletal anatomy. Taken together, these results
Cephalometric radiography can provide essential infor- indicate that the Na-Se and ANS-Me distances are closer
mation about the dimensional relationship of the cranio- to each other in men than they are in women. This
facial components, in particular, the base of the cranium, method could be used to estimate the OVD in men. The
the maxilla, the mandible, teeth, and facial soft tissue. benefits of using this objective method is that it is
As far as the authors are aware, this was the first time straightforward and reproducible for future use and does
that the possibility of predicting the OVD, measured not need additional instruments.

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A number of limitations of the study need to be
considered. First, the use of a cross-sectional design;
second, it was conducted among a relatively small sample
size; and third, it was done in participants with a class I
skeletal relationship. Another limitation of this method is
that it did not appear to be useful in women. Hence,
future studies with a larger sample size are needed to
confirm its applicability. Clinical study is also needed
among patients with edentulism to confirm its applica-
bility among those patients. Variables such as race and
sex can affect skeletal, dental and soft tissues character-
istics.28,29 These differences, therefore, should be
considered when dealing with patients from different
ethnic groups. In the current study, the measurements
and comparisons were conducted for only 1 ethnic group,
and the results are specific only to the study population
(Yemeni adults). Future studies among different ethnic
groups are recommended to identify the feasibility of
using this method among different populations.
CONCLUSIONS
Within the limitations of this clinical study the following
conclusions were drawn:
1. The Na-Se distance can be used as an additional aid
in predicting the occlusal vertical dimension in men
for the study population.
2. These measurements are sex-specific and should
not be used for both sexes.
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Corresponding author:
Dr Mohammed Nasser Alhajj
Department of Prosthodontics
Faculty of Dentistry, Thamar University
Dhamar
YEMEN
Email: m.n.alhajj@hotmail.com
Acknowledgments
The authors thank Dr Isabel Moreno-Hay (Orofacial Pain Clinic, College of
Dentistry, University of Kentucky) for guidance.
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
Alhajj and Daer