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CLASSIC ARTICLE

Vertical dimension measurements


Irving M. Sheppard, DMD,a and Stephen M. Sheppard, DMDb Monteore Hospital and Medical Center, New York, NY

ethods of obtaining measurements of vertical dimension are many and varied as indicated by Turrell1 in a discussion of 29 such methods. While the considerable importance of a proper vertical dimension of occlusion is generally accepted,2-4 the means of obtaining it are considered unreliable by some investigators,5-9 and some authors recommend the use of clinical judgment.1,8,10-12 The importance of the problem seems incompatible with the great diversity of methods for obtaining the vertical dimension of occlusion and the reliance on the something as vague and uncommunicable as clinical judgment. Many factors have been suggested as responsible for the ambiguities associated with such measurements and calculations, which include difculties in obtaining measurements on the skin of the face and the range of variability in physiologic and pathologic states.7 In an attempt to clarify some of the variables of such measurements, a previous study of vertical dimension, not employing caliper-to-skin contact, provided a denitive clue to one of the sources of confusion. A downshift (increase in the vertical dimension) of the mandibular rest position occurred upon insertion of dentures in most subjects, while an upshift (decrease in the vertical dimension of mandibular rest position) occurred in virtually all of the remaining subjects.13 This change in rest position was previously noted by Atwood.7 Our study was undertaken to determine some of the characteristics of the described changes in the vertical dimension of mandibular rest position. In addition, it includes a comparison of facial and skeletal measurements and a comparison of conventionally obtained rest space with that of existing functioning dentures.

METHODS
Fifty subjects, ranging from 48 to 80 years of age (average, 69.0 years), who wore complete dentures, ranging in age from 2.4 months to 50 years (average, 10.1
This report was supported in part by research grant DH 000961, from the Division of Dental Health, United States Public Health Services. Reprinted with permission from J Prosthet Dent 1975;34:269-77. a Research Attending. b Research Adjunct. J Prosthet Dent 2006;95:175-80.

years), were examined clinically and by use of cephalometric radiographs. The latter procedure consisted of seven cephalograms for the simultaneous recording of facial and skeletal measurements. A 6 mm lead marker was attached to the tip of the nose and the tip of the chin. While in the Cephalostat with the ear plugs lightly placed in the ears, the subject, without dentures in his mouth, was asked to swallow, to wet his lips with his tongue, and to be perfectly relaxed. Then, three radiographs were made approximately one minute apart with the edentulous mandible in the rest position. The dentures were then inserted, and the subject was asked to close in the habitual position (centric occlusion). One radiograph was made for this position. The subject was then asked to swallow, to wet his lips with his tongue, and to be perfectly relaxed. Three radiographs were then made for this, the edentoprosthetic (clinically edentulous with prostheses in place) mandibular rest position. The distance between the two facial lead markers and that between the maxillary anterior ridge and the menton were measured to tenths of a millimeter directly on the lms with a Craftsman caliper (Edmund Scientic Co, Barrington, NJ). These dimensions were reduced by 11% to compensate for the enlargement factor. Where the three edentulous rest position measurements differed, they were averaged, as were those for the edentoprosthetic rest position measurements. Where the vertical dimension of occlusion with the dentures in the mouth was found below or inferior to the edentulous vertical dimension of rest, the resulting negative or minus difference in position was increased by 3 mm to obtain the total discrepancy with conventional measurements. Measurements between the selected landmarks were repeated at a later date for two of the seven lms for each subject. The difference between the original and subsequent measurements was not statistically signicant. The data obtained were the range of facial and skeletal measurements of edentulous and edentoprosthetic rest positions; the extent of increase or decrease of the mandibular rest position upon insertion of the dentures, with subject characteristics; the amount of rest space (interocclusal distance) calculated from the difference between the vertical dimension of occlusion and the vertical dimension of mandibular edentulous rest
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Table I. Range of rest position measurements


Facial Range Average Range Skeletal Average

Table II. Range of measurements of edentulous skeletal rest position and subject characteristics
No. of subjects Average age (y) Average age of dentures (y) Average years of denture experience

Edentulous Edentoprosthetic

4.9 7.1

1.92* 1.23z

4.3 4.9

1.46 1.11

Range

*Three subjects had the same measurements for three lms. y Five subjects had the same measurements for three lms. z Six subjects had the same measurements for three lms. Thirteen subjects had the same measurements for three lms.

Less than 2 mm 2 mm or more

35 15

68.8 70.2

9.34 12.60

15.14 18.90

Table III. Measurements of change in mandibular rest position with insertion of dentures
Facial Skeletal

Table IV. Characteristics of skeletal mandibular increase or decrease in mandibular rest position upon insertion of dentures
Mean Years of Male Female Mean age of denture (%) (%) age (y) dentures (y) experience

Subjects Maximum Average Subjects Maximum Average

Increase in mandibular rest position Decrease in mandibular rest position

86%

15.1

5.25

74%

10.5

3.15

No. of subjects

14%

2.40

1.60

26%

3.0

1.41

position facially and skeletally; and the interocclusal distance existing with the dentures in place.

Total50 Increase in mandibular rest position 36 (74%) Decrease in mandibular rest position13 (26%)

34 31

66 69

69.0 69.25

10.1 8.14

10.1 15.42

39

61

70.69

21.2

23.5

RESULTS
Measurements of the edentulous rest position obtained from three different lms for each subject, made within the short time-span described, usually varied (Table I). Three of 50 subjects did not show variation in their three separate facial measurements for this position; while with ve subjects, the skeletal measurements of edentulous rest position coincided for the three lms. Two of these subjects showed no variation of these rest position measurements, either facially or skeletally. The greatest range in facial measurements was 4.9 mm with an average of 1.92 mm; while skeletally the greatest range was 4.3 mm with an average of 1.46 mm. The facial measurements of edentoprosthetic rest position were the same on three lms for each of six subjects and for 13 of 50 subjects measured skeletally. The maximum range facially was 7.1 mm with an average of 1.23 mm, and skeletally it was 4.9 mm with an average of 1.11 mm. There was a greater incidence of a constant rest position with dentures in place within the time frame described and a smaller range of average variation compared with the edentulous rest position. A summary of subjects with less than a 2 mm range of measurements of edentulous skeletal rest position and those with 2 mm or more, together with subject characteristics, is shown in Table II. Those with a greater range of measurements of edentulous skeletal rest position tended to have older dentures and more denture176

wearing experience. The latter characteristic came close to statistical signicance. A skeletal increase in mandibular rest position upon insertion of dentures occurred in 74% of the subjects, with a maximum increase of 10.5 mm and an average increase of 3.15 mm measured skeletally (Table III). An increase in mandibular rest position as determined with facial measurements occurred in 86% of the subjects, with a maximum increase of 15.1 mm and an average increase of 5.25 mm. The increase in mandibular rest position obtained with facial measurements occurred in more subjects and to a greater degree than that obtained with skeletal measurements. A decrease in mandibular rest position was found with 14% of subjects measured facially, with a maximum decrease of 2.40 mm and an average decrease of 1.60 mm. A skeletal decrease in mandibular rest position occurred with 26% of the subjects, with a maximum decrease of 3.0 mm and an average decrease of 1.41 mm. Seven subjects had an increase in mandibular rest position as measured facially and a decrease as measured skeletally. The mean age of the subjects with an increase in measurements of mandibular rest position was 69.25 years, and for those with a decrease, it was 70.69 years. The mean age of the dentures of subjects with an increase in mandibular rest position was 8.14 years, and that of those with a decrease was 21.2 years. The mean number
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Table V. Conventionally determined rest space versus actual rest space


Facial Minimum Maximum Average Minimum Skeletal Maximum Average

Edentulous rest position to occlusal position rest space Interocclusal rest space

212.5 0.0

12.4 12.7

23.23 4.24

211.6 0.0

13.8 17.5

0.22 4.41

Table VI. Edentulous rest position to occlusal position rest space vs. interocclusal rest space
Edentulous to occlusal Interocclusal rest rest space (no. of subjects) space (no. of subjects) Amount of rest space Facial Skeletal Facial Skeletal

Table VII. Edentulous rest position to occlusion, rest space


Subjects with 2.2 mm or less Subjects with 2.3 mm or more

More than 26.3 mm 26.3 to 24.3 mm 24.2 to 22.2 mm 22.1 to 20.1 mm 0.0 to 2.2 mm 2.3 to 4.3 mm 4.4 to 6.4 mm 6.5 to 8.5 mm 8.6 mm or greater

13 4 3 15 6 2 2 5

4 11 5 0 7 9 6 1 7

Edentulous to occlusal rest space Facial Skeletal Interocclusal rest space Facial Skeletal

35 27 19 14

15 23 31 36

19 9 6 10 6

4 13 10 8 5

measured skeletally and 62% measured facially had 2.3 mm or more.

of years of denture-wearing experience was 15.42 for subjects with an increase in mandibular rest position and 23.5 for those with a decrease. The subjects with a decrease in mandibular rest position tended to have older dentures and more years of denture-wearing experience (Table IV). Facial measurements of the existing interocclusal distance indicated an average rest space of 4.24 mm with a maximum of 12.7 mm (Table V). Skeletal measurements of the existing interocclusal distance indicated an average space of 4.41 mm with a maximum of 17.5 mm. Conventional calculations of rest space (i.e., the difference between the edentulous rest position and the occlusal position) yielded a negative average rest space of 23.23 mm with a maximum of 12.4 mm. The same method applied skeletally yielded an average rest space of 0.22 mm with a maximum of 13.8 mm. Twenty-one subjects had a negative rest space measured facially, while 20 subjects had a similar deciency in rest space measured skeletally (Table VI). Thus, according to conventional measurements from the edentulous rest position to the existing occlusal position, 42% of the subjects measured facially and 40% of those measured skeletally had no rest space at all. A further comparison of the conventional method of obtaining vertical dimension indicates that only 30% of the subjects measured facially had an interocclusal distance of 2.3 mm or more, although 46% had this space as measured skeletally (Table VII). The measurements of the actual existing rest space of the dentures averaging 10.1 years of use indicated that 72%
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DISCUSSION
The use of the edentulous mandibular resting position as a base line for the determination of vertical dimension of occlusion seems to present several problems. The mandible itself is a living movable structure, and it seems unlikely that it will maintain a precise rest position, at least not for any great length of time. The evidence indicates that the rest position usually varies even over a short span of time, such as the few minutes involved with the cephalometry in this study. While the average range of measurements in this position is small, the actual range with some subjects is substantial. Measurements of an usually inconstant target appear less precise when obtained from the face than from the denturesupporting skeletal structures, requiring more averaging of differing consecutive measurements. The change in the vertical position of the mandible upon insertion of the dentures evidently introduces a greater source of error when using the edentulous state as a base line for measurements. If an adequate vertical dimension of occlusion is the goal, the question arises as to whether the position of the edentulous mandible or that of the mandible supporting a denture is a natural state. It would seem that neither is. However, from a viewpoint of function, it would seem that the mandibular position associated with the prostheses, or perhaps the occlusion rims, would be more conductive to realistic measurements. This assumption seems supported by the failure of measurements of the edentulous mandibular rest position in many instances (46%, skeletally) to indicate 2.3 mm or more of interocclusal rest space
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Fig. 1. Facial measurements of vertical dimension. The subject is a 77-year-old woman with 13-year-old dentures and 13 years of complete denture-wearing experience. Level A represents a conventionally determined occlusal level obtained by subtracting 3 mm from her edentulous rest position (level B). Upon insertion of her dentures, the resting level of the mandible increased 16.9 mm to level D, while the functioning occlusal level was found at level C. According to conventional measurements, this indicates an excess opening of the vertical dimension of occlusion of 8.6 mm. However, a functioning rest space of 11.3 mm may be noted (CD).

Fig. 2. Skeletal measurements of vertical dimension for the subject shown in Fig. 1, with measurements obtained from the same lms. Level A represents the conventionally determined occlusal level obtained by subtracting 3 mm from the edentulous rest position (level C). Upon insertion of the dentures, this rest level downshifted 7.3 mm to the edentoprosthetic rest (level D), while the functioning occlusal level was found at B. According to conventional measurements, this indicates a rest space of 2.6 mm. However, a functioning rest space of 9.9 mm may be observed. This gure along with Fig. 1 illustrates some practical differences between facial and skeletal measurements. Facial measurements indicated an 8.6 mm difference between the conventionally determined occlusal position and the actual functioning occlusal position, whereas the difference measured skeletally was 2.4 mm. The increase of the edentulous rest position upon insertion of dentures was 16.9 mm when measured facially and 7.3 mm when measured skeletally. The functional rest space was 11.3 mm when measured facially and 9.9 mm when measured skeletally.

when such space did exist with 72% of the subjects with functioning dentures. The edentulous mandibular rest position failed to indicate not only the extent of change of mandibular rest position with dentures in place but also direction of change. It appears that the average increase in mandibular rest position with insertion of dentures provides 3.15 mm of rest space measured skeletally in addition to the 3 mm empirically provided by conventional measurements (Figs. 1 and 2). The 3.15 mm are, however, neither considered nor included in such conventional measurements. The average rest space would then be 6.15 mm, provided the patient is one whose mandibular
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rest position is increased with insertion of dentures. While this unplanned addition to the rest space may be a safety factor, it is apparently possible to obtain overclosure of the vertical dimension of occlusion when the increase in mandibular opening upon insertion of the dentures (downshifting) is greater than the average of 3.15 mm. Rest spaces of 7 to 13.8 mm would tend to indicate this possibility. Another example of the effect of increasing the mandibular resting position in this study occurred with 20% of the subjects who had an edentulous mandibular resting level above their functioning occlusal level with dentures in the mouth. A conventional interpretation of an adequate
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mandibular resting position would be at a level of 3 mm above the occlusal level. In effect, such use of the edentulous resting level provided no interocclusal distance at all (i.e., a negative or minus interocclusal distance); fortunately, this situation did not in fact exist because of the increase in the resting position of the mandible upon insertion of the dentures. Conventionally, these subjects would be considered to have excessive vertical dimension of occlusion. A decrease in the resting position of the mandible, which apparently can result in excessive vertical dimension of occlusion or excessive opening of the jaws, fortunately occurred less often and to a smaller degree dimensionally than did an increase in mandibular position. However, 14% of the subjects had an increase in the resting position of the mandible when measured facially and a decrease when measured skeletally. Thus, if one noted an increase in mandibular rest position with facial measurements of the edentoprosthetic rest position, such measurements would be misleading in these instances where, despite facial evidence of an increase, a decrease actually occurred skeletally. This shift in mandibular position in opposite directions may account for those instances where facial measurements provide evidence of an adequate interocclusal distance, yet the teeth may actually make contact in speech. While this contingency may develop with facial and skeletal shifting in opposite directions, it would also occur with a decrease in the mandibular resting position, both facially and skeletally. This was found with 26% of the subjects. Another characteristic of a decrease in mandibular resting position with insertion of dentures is its more frequent occurrence in long-term denture wearers. This may be related to the marked electromyographic response of the lower lip and mentalis muscles found by Tallgren14 in long-term denture wearers with impaired retention and stability of the lower denture. The imposition of the denture upon part or all of the mentalis muscle, a situation noted by Shannon15 in instances of severely resorbed ridges, may account for the electomyographic ndings and perhaps the clinical ndings of the decrease in mandibular rest position. From a practical viewpoint, it would seem that the fabrication of new dentures for a long-experienced denture wearer with old dentures can present a severe problem, particularly if an attempt is made to restore the patients original vertical dimension of occlusion. While such restoration may seem desirable from a viewpoint of esthetics, the neuromuscular reaction to the larger dentures may preclude satisfactory function. Despite excellence of t, construction, and esthetics, the elderly patient may resort to use of his old, ill-tting dentures with their reduced vertical dimension of occlusion. Old photographs or facial-prole records of patients original vertical dimension of occlusion may not
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necessarily indicate the proper mandibular level after many years of wearing dentures.

SUMMARY
Change in the vertical dimension of mandibular rest position for 50 subjects wearing complete dentures were measured on cephalometric radiographs between lead markers attached to the face and between skeletal landmarks. Measurements between the landmarks were compared on radiographs made without (edentulous) and with (edentoprosthetic) the dentures in the mouth. The ndings support the following statements. 1. The facial structures tended to mask the positional change of the mandible. 2. The rest position of the edentulous mandible tended to vary within the time frame of the cephalometric examination. 3. The range of measurements of the skeletal rest position appeared greater with greater denture age and experience of the subjects. 4. The rest position of the edentoprosthetic mandible (with dentures in the mouth) was more frequently constant when measured skeletally than when measured facially and more frequently constant than the edentulous mandibular rest position. 5. The edentulous mandibular rest position of most subjects was increased upon insertion of dentures. The rest position was decreased for the remainder of the subjects. 6. As a group, those subjects whose mandibular rest position decreased (upshifted) with insertion of dentures had older dentures and more years of denturewearing experience than subjects whose mandibular rest position increased (downshifted) with insertion of dentures. 7. The edentulous mandibular rest position does not seem particularly suitable for determination of the vertical dimension of occlusion and appears somewhat less suitable when facial measurements are used.
The authors acknowledge the assistance of Dr H. Levine, biostatistician.

REFERENCES
1. Turrell AJ. Clinical assessment of vertical dimension. J Prosthet Dent 1972;28:238-46. 2. Tench RW. Dangers in dental reconstruction involving increase of vertical dimension of the lower third of the human face. J Am Dent Assoc 1938; 25:566-70. 3. Niswonger ME. The rest position of the mandible and centric relation. J Am Dent Assoc 1934;21:1572-82. 4. Swerdlow H. Vertical dimension literature review. J Prosthet Dent 1965; 15:241-7. 5. Berry DC. The constancy of the rest position of the mandible. Dent Pract Dent Rec 1960;10:129-32. 6. McMillan DR, Barbenel JC, Quinn DM. Measurement of occlusal face height by dividers. Dent Pract (Bristol) 1970;20:177-9.

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7. Atwood DA. A cephalometric study of the mandible. Part I. The variability of clinical rest position following the removal of occlusal contacts. J Prosthet Dent 1956;6:504-19. 8. Vierheller PG. A functional method for establishing vertical and tentative maxillo-mandibular relations. J Prosthet Dent 1968;19:587-93. 9. Ismail YH, George WA, Sassouni V, Scott RH. Cephalometric study of changes in height following prosthetic treatment. J Prosthet Dent 1968; 19:321-30. 10. Brewer AA. Prosthodontic research in progress at the school of aerospace medicine. J Prosthet Dent 1963;13:49-69. 11. Standard SG, Lepley JB. The free-way space and its relation to the temporo-mandibular articulation. J Prosthet Dent 1955;5:20-32. 12. Nagle RJ, Sears VH. Denture prosthetics. St. Louis: C.V. Mosby; 1962. 13. Kleinman AM, Sheppard IM. Mandibular rest levels with and without dentures in place in edentulous and complete denture wearing subjects. J Prosthet Dent 1972;28:478-84.

14. Tallgren A. Alveolar bone loss in denture wearers as related to facial morphology. Acta Odontol Scand 1970;28:251-70. 15. Shannon JL. The mentalis muscle in relation to edentulous mandibles. J Prosthet Dent 1972;27:477-84.

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