VERTICAL DIMENSION LITERATURE REVIEW

HERBERT~WERDLOW, B.A.,D.D.S.,M.S.D.*
Bethesda, Md.

the problem of restoring and maintaining the vertical height of the

A LTHOUGH
face bears upon all the disciplines of dentistry, it is of particular importance
for those working in prosthodontics. Despite the interest and research lavished on
the investigation of the rest position of the mandible and facial vertical dimension,
certain fundamental disagreements remain unresolved.

DEVELOPMENT OF CONCEPTS OF REST POSITION

Recognition of a rest position of the mandible and the existence of an inter-

occlusal distance is not a new concept. As early as 1771, Hunter1 wrote, “In the
lower jaw, as in all the joints of the body, when the motion is carried to its greatest
extent, in any direction, the muscles and ligaments are strained and the persons
made uneasy. The state, therefore, into which every joint naturally falls, especially
when we are asleep, is nearly in the middle between the extremes of motion, by
which means all the muscles and ligaments are equally relaxed. Thence, it is, that
commonly and naturally, the teeth of the two jaws are not in contact; nor are the
condyles of the lower jaw so far back in the cavities as they can go.”
According to Gottlieb,2 a German named Wallisch was one of the first to
define the physiologic rest position of the mandible. In 1906, Wallisch described
mandibular rest position as that position of the mandible wherein all muscle action
is eliminated and the mandible is passively suspended. He reported that in this
position the opposing teeth do not contact.
Human anatomists in the early 1900’s believed in the theory that at birth
the gum pads of the jaws were in contact; and with the eruption of the teeth and
growth of the alveolar processes, the jaws were forced apart thus increasing the
vertical dimension of the face. They also believed the same process occurred in
reverse in old edentulous persons.
In the late 1920’s, Sicher and Tandler,3 restated the role of the musculature
in controlling the posture of the mandible. They stated, “the rest position of the
articulation, the ‘middle position,’ is that in which the mandible is at a slight
distance from the maxilla. In this position the mandible is kept against gravity by
the forces of the closing muscles.”
The definition of the vertical dimension of physiologic rest position accepted
by the Academy of Denture Prosthetics is: “The habitual postural position of the

‘Chief, Dental Services Branch, National Institute of Dental Research.

241
242 SWERDLOW
MaJ:gz; k

mandible when the patient is resting comfortably in the upright position and the
condyles are in a neutral unstrained position in the glenoid fossa.”

CONSTANCY CONCEPT OF FACE HEIGHT

Niswonger6v6 was perhaps the first investigator to study extensively the rest
position of the mandible by recording measurements on patients. He referred to the
rest position as the “neutral position” of the mandible since the opening and closing
muscles are in a state of equilibrium. Thus, the mandible is suspended in a resting
position with the aid of the masticatory and depressor muscles. The rest position
may be assumed voluntarily and is constantly assumed subconsciously. It makes
no difference whether the patient is edentulous, an infant, an adult, or aged.
Niswonger designed an instrument called a “jaw relator” for use in measuring
the distance that the mandible moves from rest position to centric occlusion (inter-
occlusal clearance or distance). This instrument was a guage that measured the
distance between two dots on the skin: one dot at the base of the nasal septum
and the other dot at the center of the chin. There are other such devices used for
measuring the vertical dimension of the face. The results obtained by this method
have been inconsistent because of the displacement and movement of the soft
tissues.
Niswonger studied 200 dentulous patients. He established that the interocclusal
clearance measured 4/32 inch (3+ mm.) in 87 per cent of the patients and that
the other 13 per cent varied from l/32 to 11/32 inch interocclusal clearance.
Niswonger then used another group of 200 dentulous patients ranging from 37
to 78 years of age with extremely worn occlusal and incisal edges and found
that 83 per cent of these patients had an interocclusal clearance of 4/32 inch. He
concluded that as the teeth slowly wear down, nature makes the necessary changes
in bone and soft tissues to maintain this measurement Df 4/32 inch. He found
that when an interocclusal clearance of 4/32 inch was used for 50 edentulous
patients, the dentures were satisfactory. All measurements were made from a dot
at the juncture of the philtrum with the nasal septum to a dot on the center of the
chin.
Niswonger observed that the patients whose vertical dimension of occlusion
was excessive complained that they could not use the dentures for niastication
because of continual soreness on the residual ridges. Trauma to the ridges of these
patients caused continuous tissue change until an interocclusal distance of 4/32
inch had been obtained. Not until this space had developed was the patient able
to masticate food with satisfaction and comfort.
Niswonger’s work was the beginning of the dictum that the individual man-
dibular rest position remains constant throughout life. This theory has since been
referred to as the concept of constancy of face height.
At this period of dental progress, the accepted corrective treatment for patients
with Costen’s syndrome was an opening of the vertical dimension of occlusion.
However, many observers pointed out the important role of muscle physiology in
limiting the extent to which the vertical dimension of occlusion could be increased.
Mershon7 contended that muscles cannot lengthen to accommodate an increase in
bony size, but, rather, bone adapts itself to the length of the muscles. Tenth*
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‘2” VERTICAL DIMENSION LITERATURE REVIEW 243

felt that nature may shorten muscles, but rarely, if ever, is their functional length
increased. Failures of restorations constructed at an excessive vertical dimension
of occlusion were definite proof for Tenth that the functional length of the muscles
could not be increased.
In support of Niswonger, Gillis g felt that mandibular rest position is not
artificially established but is naturally established. The interocclusal clearance does
not vary greatly between different individuals and will average 3 mm. as measured
at the central incisors. He defines rest position of the mandibl’e as “that position
from which all mandibular movements begin and to which they return.”
SchlosserlO agreed with the early investigations regarding the’ interocclusaJ
clearance. He conducted a series of phonetic expriments indicating that the move-
ments of the mandible during speech were subject to habitual fixation. Edentulous
patients were repeatedly able to bring the mandible to an identical rest position by
sounding th letter M. Schlosser also found a space of from 1 to 3 mm. between the
upper and lower incisors with the lips in contact when natural teeth were present.
Brodieil reported studies on the growth and development of the human head.
He observed that the growth pattern of the head was established by 3 months of
age. At birth, the jaws were found to be apart, with the t:)ngue occupying the
entire cavity of the mouth, extending over the ridges, and supporting the lips. With
the eruption of the teeth and growth of the jaws, the tongue, growing at a slower
rate, was gradually enclosed by the alveolar process and the teeth ; but at no time
were the teeth in occlusion.
Brodie utilized the cephalometer introduced by Broadbent in 1931.12 The
Broadbent-Boltan cephalometer has since been used extensively for the study of
the head, utilizing bony landmarks by the serially oriented roentgenographic method.
The degree of accuracy in linear measurements is much improved by elimin+ing
the errors introduced by measuring on soft tissue. The recordings are made instan-
taneously without manipulations about the face at the moment of recording. Per-
manent records are secured which can be analyzed and compared at any future time,
Thompson i3-i5 believed that the rest position is determined by a balance of
tension in the musculature which suspends the mandible, and that the rest position
is not affected by the presence or absence of teeth. He also believed that the basic
maxillomandibular relationship is established before the eruption of teeth and is
maintained after all the teeth are lost. Thompson indicated that the interocclusal
distance averaged 2 to 3 mm. in normal dentitions and may be ‘10 mm. or more in
abnormal dentitions.
In 1946, Thompsonle reported on the cephalometric analysis of the rest position
in edentulous and semiedentulous adults, The time interval for the lateral head
films varied from a few days to four years. These serial studies confirmed his opin-
ion that the rest position was stable and that it could not be permanently altered by
prosthetic restorations. He concluded that if the mandible is carried to a greater
than normal rest position by dental restorations, the mandible will return to its
“preordained” position at the expense of the alveolar process or by the intrusion of
occluding teeth. Thus, Thompson unequivocally concludes : “Without exception,
it has been shown that the mandible assumes its positional relationship to the head
by the third month of life and thereafter does not change.”
244 SWERDLOW
Marc i!-April,Pros. Den.
1965

However, in 1954, Thompsonl’ somewhat qualified his earlier statements of

the immutability of the mandibular rest position of a given individual. He recog-
nized that the rest position is related to the variations in tonicity of the involved
musculature, e.g., hypotonicity as seen in fatigue, debilitating diseases, and hyper-
tonicity such as muscle trismus. He stated, “The rest vertical dimension, established
by the mandible in its rest position, is greater than the occlusal vertical dimension,
and it is constant in most instances regardless of the status of the dentition.”
SicheF in general agreement with Thompson and Brodie, felt that the
mandibular rest position was completely dependent on the tonicity of the muscula-
ture and that only in disturbed muscle tonus as in disease, overwork, or nervous
tension could the rest position vary from normal. Since the muscle tonus is fairly
constant for each individual, the mandibular rest position is equally a fairly con-
stant position. Sicher l9 also pointed out that “constancy in a living organism means
simply that the range of variation or variability is negligible.”

VARIABILITY OF REST POSITION

During the same period in the 1930’s when the groundwork of the concept of
constancy was being developed, the literature also suggested that it was absolutely
impossible to lay down any unyeilding formula for computing exactly the correct
height of the face. Harris20 and Hight2r reasoned that the vertical dimension of the
face was dependent on the occlusal contacts in the closing movement of the man-
dible. They felt that reduction of the vertical dimension of occlusion was caused
by wearing down or abrasion of teeth, loss of posterior teeth, resorption of ridges
under dentures, and faulty dental work. Hence, the correct vertical opening in
edentulous patients was debatable.
Leof22 took issue with the doctrine that physiologic rest position is constant
throughtout life. He pointed out that physiologic manifestations in the body, such
as blood pH and temperature, were not fixed but rather have a range that changes
with health, disease, emotional state, and age. He stressed that muscle tone rather
than muscle length controls the rest position, and that muscle tone can and does
vary. Muscle tone can be increased by exercise and decreased by excessive rest.
Hypertonicity of mandibular muscles can be developed through clamping and/or
grinding habits which may interfere with the maintenance of a constant rest posi-
tion and result in a reduction of the normal interocclusal distance. Leof further
stated that we must never eliminate the interocclusal distance. With excessive
increase of the vertical dimension of occlusion, there is a concomitant hazard of
initiating a clamping and/or grinding habit where one had never existed before.
The physiologic rest position of the mandible was studied roentgenographically
by Olser?* on 70 edentulous individuals with and without dentures. His findings
suggested that the resting position was not rigidly stable. The mean rest measure-
ment with dentures in place was greater than-the comparable measurement without
dentures in 83 per cent of the patients. Thus, the wearing of dentures directly
influenced the resting height of the face and had clinical implications.
Perhaps one of the, most extensively documented studies in this country on
rest position was performed by Atwood. 24 A longitudinal roentgenographic analysis
of face height before and after extraction was performed on 42 subjects. This
~%iEr
‘2” VERTICAL DIMENSION LITERATURE REVIEW 245

study demonstrated variability within a sitting, between sittings, and between

readings with and without dentures. A decrease in the vertical dimension of man-
dibular rest position wa.& clearly shown following the removal of opposing occlusal
contacts. Atwood pointed out that the degree of variability of the clinical rest
position in a patient depended on the relative values of and complex interplay
between some 30 influential factors.’
Tallgren”” studied the changes in adult face height by means of a roentgeno-
graphic cephalometric technique. Her findings were similar to those of AtwoodzJ
and Olsenz3 in showing a certain instability of the rest position after removal of
teeth. Pronounced changes in face height were reported after extraction and during
the first year after prosthetic treatment in a longitudinal study of 32 subjects
wearing complete dentures. The changes in the resting height of the face seemed
to adapt to alterations in the morphologic face height. The interocclusal distance
appeared to be conditioned by the functional requirements of the masticatory ap-
paratus.
The rest position as a guide in prosthetic treatment was studied by Duncan
and Willianls.“6 Lateral roentgenographic cephalometric measurements were made
on 10 patients for whom complete dentures were construed. They found a reduction
in the pre-extraction height of the face with the teeth in occlusion, as related to
the corresponding height of the face after prosthetic treatment, in all but one sub-
ject. A general reduction in the height of the face with the mandible in rest position
was also observed after removal of occlusal contacts. The instability found in rest
position led these investigators to conclude that rest position is a poor guide for
establishing the pre-extraction occlusal vertical dimension.
Swerdlow27 followed a group of 40 immediate denture patients over a 6-month
period. Changes in the occlusal vertical dimension, rest vertical dimension, and
interocclusal distance were recorded cephalometrically during the transition from
natural teeth to immediate dentures. The conclusions and observations from this
investigation were. (1) the phonetic method of recording rest position gave con-
sistently greater values for interocclusal distance than did the swallowing method.
(2) The occlusal vertical dimension and rest vertical dimension increased initially
and then decreased markedly in the six months of wearing dentures. (3) The
interocclusal distance adjust itself to accommodate to the variations in facial
vertical dimension. (4) A change in mandibular load appears to influence the rest
position of the mandible. (5) The data presented indicate the need for periodic
recalling of denture patients for appraising and re-establishing facial vertical dimen-
sion before accommodation into an undesirable functional and esthetic relation
dominates the mandibular posture.
Coccaro and Lloyd2* performed a longitudinal cephalometric analysis of 22
patients wearing complete dentures. Despite the alterations introduced in the verti-
cal dimension of occlusion at the time of initial placement of the dentures, a general
reduction in the morphologic face height was found after the patients wore the
complete dentures for 12 months. The greatest percentage of change was noted
during the first 6 months. As would be expected, the greatest change was recorded
in the dimensions of the middle part of the face. A forward positioning of the
mandible, which resulted in a facial profile that was more prognathic, was associated
with the loss in the vertical dimension of occlusion.
246 SWERDLOW J. Pros. Den.
March-April, 1965

CONCLUSIONS

A major cause of failure in denture construction is the establishment of an

incorrect vertical dimension ot occlusion. This problem is being attached vigorously
in many parts of the world. The development of new investigative tools and better
interpretation of the available methods for establishing the height of the face in-
dicate that eventually these measurements will be more accurate and practical.
The division of opinion, the lack of satisfactory solution to problems of
vertical dimension, and the paucity of systematic studies are some of the factors
which should stimulate an increased effort by investigators in this subject.

REFERENCES

1. Hunter. J.: The Natural History of the Human Teeth, ed. 1, London, 1771, John Johnson.
2. Gottlieb, B.: Traumatic Occlusion and the Rest Position of the Mandible, J. Periodont.
18:7-20,1947.
3. Sicher, H:, and Tandler, J.: Anatomie fiir zahnaerzter, Wien and Berlin, 1928, Julius
Sprmger.
4. The Academy of Denture Prosthetics: Glossary of Prosthodontics Terms, ed, 2, J. PROS.
DEN. 10: Nov.-Dec. suppl., 1960.
5. Niswonger, M. E.: The Rest Position o fthe Mandible and the Centric Relation, J.A.D.A.,
21:1572-1582, 1934.
6. Niswonger, M. E.: Obtaining the Vertical Relation in Edentulous Cases that Existed prior
to Extraction, J.A.D.A. 25:1842-1847, 1938.
7. Mershon, J. V.: Bite-opening Dangers, J.A.D.A. 26:1972-1979, 1939.
8. Tenth R. W. : Dangers in Dental Reconstruction Involving Increase of the Vertical Dimen-
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9. Gillis, R. R.: Establishing Vertical Dimension in Full Denture Construction, J.A.D.A.
28:430-436,1941.
10. Schlosser, R. 0.: Methods of Securing Centric Relation and Other Positional Relation
Records in Complete Denture Prosthesis, J.A.D.A. 28:17-25, 1941.
11. Brodie, A. G. : Growth Pattern of Human Head From Third Month to Eighth year of Life,
Am. J. Anat. 68:209-262, 1941.
12. Broadbent B. H.: New X-ray Technique and Its Application to Orthodontia, Angle Ortho-
don&t 1:45-66,1931.
13. Thompson, J. R.: A Cephalometric Study of the Movements of the Mandible, J.A.D.A.
28:750-761, 1941.
14. Thompson, J. R., and Brodie, A. G.: Factors in the Position of the Mandible, J.A.D.A.
29:925-941, 1942.
15. Thompson, J. R.: The Constancy of the Position of the Mandible and Its Influence, on
Prosthetic Restorations, Illinois D. J. 12:242-247, 1943.
16. Thompson, J. R.: The Rest Position of the Mandible and Its Significance to Dental Science,
J.A.D.A. 33:151-179, 1946.
17. Thompson, J. R.: Concepts Regarding Function of the Stomatognathic System, J.A.D.A.
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19. Sicher, H.: Oral Anatomy, ed. 3, St. Louis, 1960, The C. V. Mosby Company, p. 173.
20. Harris, H. L.: Effect of Loss of Vertical Dimension on Anatomic Structures of Head and
Neck, J.A.D.A. and D. Cosmos, 27:175-193, 1936.
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1447~145f$.1936.
22. Leaf, M.: Revlslon of Accepted Dicta on Mandibular Position, New York J. Den. 20:
8-14,1950.
23. Olsen, E. S.: A Radiographic Study of Variations in the Physiologic Rest Position of the
Mandiblein SeventyEdentulousIndividuals, Thesis, University of Minnesota, 1951.
24. Atwood, D. A. : A CephalometricStudy of the Clinical Rest Position of the Mandible.
Part I: The Variability of the Clinical Rest Position Following the Removal of
Occlusal Contacts, J. PROS. DEN. 6:504-519, 1956; Part II. The Variability in the
Rate of Bone Loss Following the Removal of Occlusal Contacts, J. PROS DEN.
7:544-552, .1957; Part III. Clinical Factors Related to Variability of the Clinical
~${~ll$;flon Followmg the Removal of Occlusal Contacts, J. PROS. DEN. 8:698-
, *
iz%r‘2” VERTICAL DIMENSION LITERATURE REVIEW 247

25. Tallgren, A.: Changes in Adult Face Height Due to Aging, Wear, and Loss of Teeth and.
Prosthetic Treatment, Acta. odont. scandinav. 15:1-K!& suppl. 24, 1957.
26. Duncan, E. T., and Williams, S. T.: Evaluation of Rest Position as a Guide in Prosthetic
Treatment, J. PROS. DEN. 10:643-650,1960.
27. Swerdlow, H.: Roentgencephalometric Study of Vertical Dimension Changes in Immediate
Denture Patients, J. PROS. DEN., 14:635-650,1964 .
28. Coccaro, P. J., and Lloyd, R. S.: Sephalometric Analysis of Morphologic Face Height,
J. PROS. DEN. 15:35-37,1965.
DENTAL SERVICES BRANCH
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NATIONAL INSTITUTES OF HEALTH
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