CE

Approaches to Vertical Dimension

Abstract: Vertical dimension is a highly debated topic in dentistry. Differences of opinion over how
vertical dimension should be established, whether it can be modified, and what the outcome of
modification will be can become confusing for those dentists searching for the right treatment for their
patients. The fact is that there are multiple different approaches because there are several correct ways
to alter vertical dimension. This article will address the most common reasons dentists consider altering
vertical dimension, their five top areas of concern, and the methods by which vertical dimension can
be established.

I n dentistry there are areas of inter-

est that provoke heated debate
among different groups of practi-
the gonial angle of the mandible, and
the eruption of the teeth. As the ramus
grows, the teeth continue to erupt, main-
tioners. Vertical dimension is one of taining the occlusion. There can be,
those topics. There are practitioners however, significant differences in the
who vehemently defend their position length of the ramus, which has a sig-
as to how vertical dimension should nificant impact on anterior facial height
be established, whether it can be mod- or vertical dimension. In what would
Frank M. Spear, DDS, MSD
ified, and what the outcome will be be considered normal or ideal ramus
Founder and Director if it is modified incorrectly. Other development, the midface, measured
Seattle Institute for Advanced
Dental Education
practitioners hold the exact opposite from glabella to the base of the nose, is
Seattle, Washington beliefs with equal intensity. These dif- roughly equal in measurement to the
Affiliate Assistant Professor
ferences of opinion become confusing, lower face measured from the base of
University of Washington because most clinicians are searching the nose to the bottom of the chin at
School of Dentistry
Seattle, Washington
for the right answer with regard to the completion of growth. As ramus
how patients should be treated. As a length varies, both anterior facial height
Private Practice
Seattle, Washington
general rule, any time multiple dif- and tooth display vary. Differences in
ferent approaches exist for a long ramus length are primarily influenced
period of time in dentistry, it is proba- by genetic variations.1-11 A patient who
bly because there are several correct has a short ramus with normal posterior
answers to the same problem. As tooth eruption will have an increased
we will see, that is the case with verti- anterior facial height and an anterior
Learning Objectives cal dimension. open bite. Often, however, the anterior
teeth in such a patient overerupt to
After reading this article, the Understanding Occlusal maintain the occlusion, creating both
reader should be able to: Vertical Dimension excessive tooth and gingival display.
The Glossary of Prosthodontic Terms Commonly, the patient with a short
explain how vertical dimension defines occlusal vertical dimension as ramus shows a long lower facial height
is established during growth the distance between any point on the when compared with their midfacial
and development. maxilla and any point on the mandible height. This patient has excessive gingi-
discuss the five most common where the teeth are in maximum inter- val display and is often treated with a
concerns of practitioners when cuspation. Commonly, nasion and men- maxillary impaction to decrease their
considering an alteration of ton are used for these points. vertical dimension (Figures 1 and 2).12-16
vertical dimension. A patient who has a long ramus with
Vertical Dimension during normal posterior tooth eruption will
describe the different beliefs Growth and Development have the opposite facial appearance to
about how vertical dimension Three factors affect the occlusal that of the person with a short ramus.
should be established. vertical dimension during growth and Commonly, this patient will have a
development: the growth of the ramus, very short lower face in comparison to
2 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006
their midface and may have inade-
quate maxillary tooth display. Unlike
the long, slender face of the short
ramus patient, the long ramus patient
may have a very square face (Figures 3
and 4). Treatment of the vertical dimen-
sion of the long-ramus patient often
involves a double jaw surgery to rotate
the chin inferiorly as well as the maxil-
la to increase lower facial height and
increase maxillary tooth display. This Figure 1A patient with a short ramus exhibiting a long anterior facial height, excessive tooth and
gingival display, and a significantly longer, lower face than midface. The patient shows 8 mm of tooth
surgery has the impact of lengthening at rest, 5 mm more than would be normal for her age.
the overall face and increasing the
patients vertical dimension while at the
same time maintaining the length of
the ramus or overall posterior vertical
dimension.17-22 The patients gonial
angle also has an impact on the patients
anterior vertical dimension. A patient
with an acute gonial angle has a ten-
dency to mimic the facial features of a
patient with a long ramus, with a square
face and short lower face compared to
their midface. These patients are com-
monly referred to as having a flat man-
dibular plane angle. Patients who have
Figure 2Before and after photographs of the patient seen in Figure 1 after a maxillary impaction to
more obtuse gonial angles mimic the reduce the excessive tooth and gingival display and reduce the vertical dimension.
appearance of patients with short ramus
heights, with a long narrow face, exces-
sive tooth and gingival display, and a
long lower face when compared to their
midface. Patients with more obtuse
gonial angles often are referred to as
having steep mandibular plane angles.
There appears to be some evidence that
the formation of the gonial angle may
be influenced by the strength of the
masseter muscle. The stronger and more
developed the masseter muscle is, the
more pronounced or acute the gonial Figure 3A patient with a long ramus. Note the reduced anterior facial height and very square facial
angle is (Figure 5).22,23 In addition to appearance.
ramus length and gonial angles, tooth
eruption plays a critical role in the
development of a patients vertical
dimension. In normal growth and
development, the maxillary and man-
dibular teeth erupt to maintain occlusal
contact as the face grows. There can be
variations, however, in tooth eruption
that can result in alterations in facial
vertical dimension. After growth is
completed, tooth eruption is necessary
to maintain the vertical dimension if
any wear occurs. If eruption occurs at
the same rate as tooth wear, the verti-
cal dimension of the patient will be
CE

Figure 4Before and after photographs of the patient seen in Figure 3 after double-jaw surgery to
unchanged. If, however, the eruption rotate the mandible and the maxilla inferiorly, increasing tooth display and anterior facial height.
does not keep up with tooth wear, the
Vol. 2, No. 3, 2006 Advanced Esthetics & Interdisciplinary Dentistry 3
Figure 5The impact of ramus length and gonial angle on lower facial height and mandibular plane angle. Note the reduced lower facial height in the
example with a long ramus and flat angle, and the exaggerated lower facial height in the example with the short ramus and steep angle.

vertical dimension may decrease with Effects on the Temporal regarding muscle pain. When evaluating
time. The question of whether eruption Mandibular Joint the literature it is prudent to examine
keeps up with tooth wear to maintain To address these concerns, it is help- how the research was done. There are
vertical dimension is one of the most ful to evaluate the literature on the several papers that have concluded that
heated debates in dentistry.24-27 alteration of vertical dimension and its altering vertical dimension produces
impact in each of the five areas. With symptoms such as headaches, muscle
Clinical Alterations of regard to pain in the temporal mandibu- aches, and muscle fatigue.32-34 The
Vertical Dimension lar joint, the literature is clear that if problem with several of these research
Having described how vertical di- the joint is comfortable at the existing projects is that they altered vertical
mension is established during growth vertical dimension, it is highly unlikely dimension by building up only the
and development, it is now important that the joint will experience any discom- posterior teeth without any anterior
to discuss why vertical dimension might fort at an altered vertical dimension. It contact or anterior guidance. At the
be changed clinically. The most com- is possible, however, in the event of end of the study, several of the patients
mon reasons dentists consider altering anterior disc displacement, that alter- reported muscle symptoms and it was
vertical dimension are: 1) to improve ing vertical dimension may change the concluded that it was a result of the
esthetics by altering facial form and/or relationship of how the condyle com- change in vertical dimension. In fact,
tooth and gingival display; 2) to improve presses retrodiscal tissue posterior to the patients were left with an occlusal
occlusal relationships, such as correcting the displaced disc (Figure 6). In some scheme that would not be created clini-
anterior open bites; and 3) to gain space instances, increasing the vertical dimen- cally. If the articles regarding the impact
for the restoration of short or worn teeth. sion may benefit the relationship of of vertical dimension changes on mus-
Practitioners often mention five areas the condyle to the disc, whereas in oth- cles are limited to those that created
of concern about altering vertical dimen- er circumstances it is possible that a an ideal occlusal scheme simply at dif-
sion. Will the vertical alteration have a change in vertical dimension may have ferent vertical dimensions, it is clear
negative effect on the temporal mandibu- a negative effect. If the patient is having that altering vertical dimension does not
lar joint? Will muscle pain be a side significant joint symptoms, it will be produce muscle pain. In fact, less than
effect of the change in vertical dimen- necessary to try out any vertical changes 5% of the patients had any short-term
sion? Will the vertical dimension be in an appliance to predict the impact of muscle awareness, which disappeared
stable in its new position? Will muscle the vertical dimension on the patients 2 weeks after the vertical alteration.35-40
activity levels be altered, increasing symptoms. It is critical that when the
bite force and potentially increasing vertical dimension is altered, there are Stability of Altered
the failure rate of restorations? Will stable posterior occlusal contacts, be- Vertical Dimensions
speech be affected in a negative way? cause a lack of posterior occlusion can Another area of concern that gen-
significantly increase the load on the erates heated debate is the stability of the
joints. Alterations in vertical dimension vertical dimension after any changes.
do not have a negative impact on tem- Two basic schools of thought exist. One
poral mandibular joints unless the joint believes that any change in vertical
suffers from an internal derangement. dimension will be followed by a return
Even then there is a high likelihood to the previous vertical dimension
that a vertical alteration will not nega- through tooth intrusion or tooth erup-
tively affect the joint.28-31 tion. This group believes that the length
of the masseter muscle and medial
Figure 6This illustration shows how the
Muscle Pain pterygoid are fixed and, therefore, any
condyle compresses retrodiscal tissue after The next area of concern in alter- alteration in the vertical dimension of
anterior disc displacement. ing vertical dimension is the impact occlusion will revert back to the previous

4 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006

vertical dimension because of the fixed This surgical approach has proven
nature of the muscles (Figure 7). The very stable.
second group believes that vertical The two previous examples involved
dimension is adaptable and that changes orthognathic surgery and significant
in the vertical dimension of occlusion alterations to vertical dimension. Liter-
are maintained because of an alteration ature searches on more traditional meth-
in the length of the muscles. The fact ods of altering vertical dimension, such
that these arguments between the two as through the use of restorative den-
groups have gone on for decades should tistry, do not show clear conclusions
Figure 7This illustration shows how the mas-
give us some clue as to the confusion with regard to stability. Some articles seter muscle is related to anterior vertical
regarding stability. show very little or no relapse occur- dimension via its insertion points on the maxilla
It may be that both groups are cor- ring, whereas others indicate a more and the mandible.

rect some of the time. The literature significant relapse occurring. In some
definitely shows examples of a relapse instances, the patients with the high-
toward the original vertical dimension est percentage of relapse were those
occurring after an alteration in vertical that had the smallest actual change in
dimension. This relapse could be an vertical dimension.47-52
increase in vertical dimension after a The reason so much confusion exists
significant closing of the vertical dimen- regarding stability may in fact have to
sion, which might occur after maxil- do with the geometry of the temporal
lary impaction surgery. However, the mandibular joint, masseter muscle,
relapse in these circumstances may be medial pterygoid muscle, and anterior
only a small percentage of the actual teeth. Most alterations to vertical dimen- Figure 8A superimposition of the before and
change that occurred.41-43 Conversely, sion are measured at the anterior teeth, after cephalometric radiographs from the
certain clinical procedures may be asso- with a 3-mm alteration in anterior ver- patient in Figures 3 and 4. There has been no
change in molar position but a 5-mm inferior
ciated with significant relapse, such as tical dimension resulting in less than movement of the chin has increased the anteri-
down-fracturing the maxilla to increase 1 mm of change in masseter muscle or vertical dimension without changing the
tooth display and facial height in the length. Additionally, if the condyle is posterior vertical dimension.
patient with a long ramus and square seated in the fossa of the temporal
face. Immediately after surgery, the mandibular joint during treatment,
vertical change may look excellent, but for each millimeter the condyle is seated
statistically these patients experience vertically the masseter muscle length is
significant relapse.44-46 It is for this reduced almost 1 mm. It is, therefore,
reason that today these patients are treat- possible that if the condyle is seated as the
ed with double-jaw surgery, because the anterior vertical dimension is increased,
posterior portion of the mandible, there will be minimal, if any, change in
including the insertion of the masseter masseter or medial pterygoid muscle
and medial pterygoid muscle, is not length, and there would be no expec-
altered during the surgery. Instead, the tation of relapse (Figure 9). However, Figure 9This illustration shows the geometry
body of the mandible and the maxilla if there was no alteration in the vertical relating increases in anterior vertical dimension
to decreases in posterior vertical dimension
are rotated inferiorly to improve tooth position of the condyle as the anterior from the seating of the condyle.
display and facial height while maintain- vertical dimension was increased, a
ing the length of the muscles (Figure 8). change in muscle length would have

Figure 10Three stages in the treatment of a patient whose vertical dimension was increased. At the far left is the pretreatment vertical dimension. The
middle shows the provisional restorations 6 months postinsertion. The far right shows 5 years after seating of the final restorations. It appears that during
CE

the 4.5 years between the middle photograph and the right photograph no change has taken place in terms of vertical relapse. However, it is possible had
this patient been monitored with cephalometric radiographs for some relapse to have occurred in the distance between the maxilla and the mandible with-
out the patient or the clinician realizing it, and with the occlusion remaining the same.

Vol. 2, No. 3, 2006 Advanced Esthetics & Interdisciplinary Dentistry 5

 dimension, the muscle activity is similar
to pretreatment levels. This is a critical
finding because any treatment that
attempts to modify muscle activity levels
by altering vertical dimension can only
be successful on a short-term basis
because of the bodys natural neuro-
muscular adaptability.

Effects on Speech
The final area of concern when
altering vertical dimension concerns
Figure 11Patients use different methods to create sibilant sounds. On the far left is the intercuspal
position. In the middle, a patient makes sounds using the lingual of the maxillary incisors. On the far phonetics, particularly the sibilant or
right is a patient who postures the mandible forward, making sibilant sounds between the maxillary S sounds. As a general rule, there is a
and mandibular incisal edges.
high level of adaptability by most
patients with regard to speech. After a
short period of time, usually 1 week to
4 weeks, most patients will learn to
reprogram their speech patterns to any
alterations that have been made den-
tally. There are, however, patients in
whom this adaptation does not occur.
To understand how this might be relat-
ed to vertical dimension it is important
Figure 12On the left is the patient seen in Figure 10, 1 month after the provisional restorations had to understand the differences in how
been placed, increasing the vertical dimension. On the right is this patient saying 66 and lisping
during sibilant sounds. It was necessary to reduce the mandibular incisors to correct phonetics. patients make sibilant sounds. The
majority of people make S sounds
occurred, and may be responsible for is clenching. As the vertical dimension by moving their mandible forward so
any relapse. is increased, resting muscle activity that the incisal edges of the mandibular
Because none of the studies47-52 actually decreases. The more open the incisors are end-to-end with the incisal
assessed the change in condylar posi- vertical dimension is, the less activity edges of the maxillary incisors (Figure
tion and related it to the alteration in is present in the muscles in a postural 11). For these patients, it is the incisal
anterior vertical dimension, it is impos- position. This decrease in muscle activi- edge position of the teeth that can cre-
sible to make that conclusion. The real ty occurs until there is approximately ate phonetic problems if a significant
question concerning stability is what 10 mm to 12 mm of anterior vertical increase in incisal ledge length occurred
clinical impact any relapse would have opening. Opening beyond 10 mm to to either the maxillary or mandibular
on the patient. It would appear that 12 mm starts to increase elevator muscle incisors. The teeth may now collide
even in the studies where some relapse activity. Interestingly enough, if the during the S sounds, generally result-
occurred, the patients involved were vertical change is maintained for 3 to ing in a whistling or slurring any time
basically unaware of the relapse and 4 months, the resting muscle activity a sibilant sound is made. This can be
experienced no symptoms. Unless an returns to a level closely matching the evaluated clinically by simply having
operator was evaluating vertical dimen- pretreatment resting muscle activity the patient say 66 or 77 and watch-
sion using radiography, the clinician level, although the vertical dimension ing to see if the anterior teeth touch
would not see any changes posttreat- has not been decreased.53-56 during the sibilant sound. If they do,
ment (Figure 10). The conclusion con- The impact of increasing vertical and the patient has been given 2 to 4
cerning stability is that it is an unknown dimension on clenching muscle activity weeks to adapt and has not, it will be
entity; that is, the patient may or may is the opposite; as the vertical dimension necessary to shorten either the upper or
not experience some relapse, but the is increased, the electrical activity level the lower incisor. If the upper incisor
treatment will remain successful. in the elevator muscles increases during can be shortened it is possible to cor-
clenching beyond their pretreatment rect the phonetics and not alter the
Impact on Muscle Activity Levels level. Again, however, if the vertical centric occlusal contacts at all. However,
The fourth area of concern when dimension is maintained for 3 to 4 although it is possible to shorten the
altering vertical dimension is the impact months, this increased level of clenching lower incisor to correct speech, it is
on muscle activity levels. There are electrical activity similarly reduces to necessary to remove the centric con-
two components to the activity levels pretreatment levels.57-60 In summary, tact on the lingual of the maxillary
of muscles: the muscle activity level although there is an initial change both incisor. If the centric contact can be
when the mandible is at rest and the in resting and clenching activity levels, gained by adding material to the lin-
muscle activity level when the patient after 3 to 4 months at the new vertical gual of the maxillary incisor, vertical
6 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006
dimension will not be affected. However, lips, swallow, and relax. Most schools and a mild, cyclic electrical current is
if it is not possible to add material on the advise a 2-mm to 4-mm freeway space generated to stimulate contraction of
lingual of the maxillary incisor, it will as normal, so if there is a desire to the muscles of mastication by way of the
be necessary to either close the vertical increase the vertical dimension on a cranial nerves. The surface electrical
dimension to regain centric contact denture it is necessary that the patient activity of the temporalis, masseter, and
restoratively or leave the patient with an have more than 4 mm of freeway space digastric muscles are recorded elec-
anterior open bite, risking secondary with their existing dentures. The free- tromyographically, and a jaw-tracking
eruption and instability (Figure 12). way space then determines how much device evaluates the position of the
The second method by which the vertical dimension can be increased. mandible relative to the maxilla. A base-
patients make sibilant sounds is between This method of using freeway space to line electromyographic reading is taken
the mandibular incisal edge and the determine vertical dimension has been before any muscle relaxation. The TENS
lingual contour of the maxillary inci- used for decades in denture prostho- unit is then started to relax the muscles
sors. If vertical dimension has been dontics. It is important to note, how- of mastication and the electrical activity
increased restoratively in these patients, ever, that freeway space is only being of the muscles evaluated. Neuromus-
any problems with phonetics will be used to mount the models and set the cular rest is achieved when the elevator
between the mandibular incisal edge teeth for the denture try-in. At the try- muscles are at their lowest level of activ-
and the lingual contour of the maxil- in, phonetics and esthetics are used to ity without an increase in the electrical
lary incisors. Again, if after 2 to 4 weeks refine final incisal edge position and activity of the digastric muscles. This
of adaptation the patient is still having vertical dimension. The challenge of neuromuscular rest position is thought
difficulty making S sounds, it will using freeway space for patients who to be the starting point for the building
be necessary to provide a speaking space. still have their natural teeth is that as of the occlusion. The operator closes
This can be done by shortening the low- the vertical dimension is changed; mul- up from this position for the new
er incisor or removing material from tiple studies have found that freeway amount of freeway space, effectively
the lingual of the maxillary incisor. In space recreates itself within the subse- using the combination of neuromuscu-
either case, however, it is highly likely quent 4 weeks. Because of this, the use lar rest and freeway space to determine
that the centric contact will be removed of freeway space to determine whether the new occlusal vertical dimension.
and since the S sound is now made vertical dimension can be altered is not The primary flaws of this approach
on the lingual of the maxillary anterior supported by research for patients who relate to the neuromuscular adaptability
teeth, the only method to regain anteri- still have natural teeth.66-77 of patients. As discussed earlier, the rest-
or contact is to close the vertical dimen- ing electrical activity of muscles, as well
sion.61-65 In summary, with regard to Trial Appliances as freeway space, relapse toward pretreat-
the five major concerns about altering Another method of determining ver- ment levels from 1 month to 4 months
vertical dimension, it is obvious from tical dimension is the use of a trial splint posttreatment. Also, this approach often
reviewing the literature that changes in or appliance. The patient is asked to results in a vertical dimension more
vertical dimension are well tolerated in wear an acrylic appliance, typically for open than the patients existing vertical
the majority of patients and there is no 3 months, to evaluate if the new vertical dimension, which can lead to the need
evidence that there is only one correct dimension can be tolerated. The theory for an extensive amount of restorative
vertical dimension. behind this is that the patient will expe- dentistry and extremely large teeth, sim-
rience pain if the vertical dimension is ply to accommodate the vertical dimen-
Determining a New not acceptable, but the challenge of sion that was dictated by the equipment.
Vertical Dimension this approach is that outside of a few
The next question that clinicians patients with temporal mandibular joint Measurements Using the
frequently ask is how to determine a problems, altering vertical dimension Cementoenamel Junction
new vertical dimension. Historically, does not produce pain. Although the Another methodology that has
several techniques have been used, appliance may be very useful to deter- been described78,79 to determine ver-
many from denture prosthodontics. mine other elements of treatment or tical dimension is to measure from the
to aid in muscle deprogramming, it cementoenamel junction (CEJ), or gin-
Using Freeway Space does not provide specific information gival margins of the maxillary central
The first technique most dentists are regarding vertical dimension. incisors to the CEJ, or gingival mar-
exposed to concerning vertical dimen- gins of the mandibular central inci-
sion is the use of freeway space. Freeway Transcutaneous Electrical sors. This distance is then compared to
space is defined as the distance between Neural Stimulation the 18-mm to 20-mm average distance
the maxillary and mandibular teeth A third methodology that has also seen in a dentition of unworn teeth
when the mandible is in its postural been used for decades to determine and a class I occlusion. If this distance is
position. Several different techniques vertical dimension is the use of tran- less than 18 mm, it probably indicates
have been used to reproduce this pos- scutaneous electrical neural stimulation a loss of vertical dimension and is,
tural position, from having the patient (TENS). In this approach, electrodes therefore, a rationale for increasing it.
say M, to having them lick their are applied over the coronoid notch The primary flaw of this approach is
8 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006
that the anterior teeth do not establish anterior teeth it is also likely that ortho- proportion and still allow a correct
the vertical dimension of occlusion; it dontics or crown lengthening would occlusal relationship. As the vertical
is established by the length of the ramus allow the patient to be treated without dimension is increased or decreased,
and the eruption of the posterior teeth. the need to treat their posterior teeth. overjet is also altered significantly; for
Measuring the distance between the each 3-mm vertical change in the anteri-
CEJ or gingival margins simply evaluates The Method of Facial Proportion or teeth, there is approximately a 2-mm
the amount of anterior tooth eruption, As discussed in the introduction, horizontal change in an anteroposterior
not the vertical dimension of occlusion. facial proportion is another method that dimension. This 2-mm change is an
It is in fact possible to have an extremely has been described in the literature81,82 alteration in overjet. Therefore, attempt-
diminished CEJ-to-CEJ distance in the for determining vertical dimension. In ing to increase the vertical dimension by
anterior and a perfectly normal vertical this approach, the theory is that the 6 mm will result in a 4-mm increase in
dimension of occlusion. This can occur vertical dimension of occlusion should overjet, making it almost impossible
commonly in patients with severe ante- be created in a way that corrects facial to have correct anterior occlusal contact
rior tooth wear and no posterior tooth proportion. In an ideal face, the midface unless the patient started out with a
wear (Figure 13). 80 Most clinicians and the lower face are approximately class III occlusion. In addition to this
examine the worn anterior teeth and equal in height. The method of facial fundamental flaw regarding overjet, it is
decide to open the bite to gain space for proportion alters the length of the lower almost impossible for the orthodontist
restoration, when in fact by intruding face to correspond to the length of the or restorative dentist to correct facial
the worn anterior teeth or crown length- midface by altering the length of the proportion if the patients lower face is
ening them to correct the gingival lev- teeth. Although this approach may be excessively long and the vertical dimen-
els the patient could be treated at the entirely appropriate for an orthog- sion needs to be closed. Finally, in a
existing vertical dimension (Figures 14 nathic surgeon who has the ability of study evaluating whether dentists were
and 15). As a general rule, if the poste- making significant alterations in man- capable of seeing the facial differences
rior teeth are present, unworn, and in dibular position, it is extremely difficult caused by changes in vertical dimen-
occlusion, it is highly unlikely that the for an orthodontist or restorative den- sions of 2 mm, 4 mm, 6 mm, or 8 mm,
patient has lost vertical dimension. If tist to make large variations in vertical Gross83 found that until the change
there is a lack of space to restore the dimension that would influence facial reached 8 mm, dentists were unable to
assess the difference in facial features.
This is quite logical, as the only time a
patients vertical dimension of occlu-
sion is generally evaluated is when their
teeth are together; typically in most of
lifes activities the teeth are apart and
therefore not affecting facial proportion.
In fact, it is the authors belief that it is
the change in tooth display when verti-
Figure 13On the left, a 29-year-old patient with minimal or no posterior wear but severe anterior
wear. On the right is the same patient in occlusion. Measuring from the gingival margins of the ante- cal dimension is opened that dramati-
rior teeth makes it appear as though the patient has lost a vertical dimension but this is an illusion cally alters a patients esthetics, not the
because of the overeruption of the worn anterior teeth.
facial change because of the change in
vertical dimension.

Choosing the Right Vertical

Dimension for the Patient
After reviewing many of the different
techniques for determining vertical
dimension it is easy to see the flaws in
all of them, and yet they all have been
Figure 14Initial and treatment photographs of the patient seen in Figure 13. The mandibular ante-
rior teeth have been built up and then orthodontically intruded, creating space for restoration.
used successfully, many of them for
decades. This means that vertical dimen-
sion is a highly adaptable position, and
there is no single correct vertical dimen-
sion. Furthermore, using a particular
vertical dimension as the rationale to
reconstruct teeth which otherwise do
not need treatment is not scientifically
justified. If the patient does need an ex-
CE

Figure 15Before and after photographs of the patient seen in Figures 13 and 14. The patient was
treated with orthodontics and four maxillary incisors and four mandibular incisor full crowns. No tensive reconstruction, several different
changes were made to the patients vertical dimension. vertical dimensions could be successful.
Vol. 2, No. 3, 2006 Advanced Esthetics & Interdisciplinary Dentistry 9
This ultimately leaves us with the ques-
tion of which one to choose. In answer-
ing that question, and because many
different vertical dimensions may be
successful, it makes the most sense to
the author to choose the one that sat-
isfies the patients esthetic goals and
the clinicians functional goals. In many
Figure 16The initial presentation of a 65-year-old man with severe anterior tooth wear desiring
ways this is the simplest of all methods esthetic improvement.
for determining vertical dimension:
The first step is to mount the patients
existing models with the seated condyle.
The second step is to establish on the
maxillary model the ideal maxillary
central incisor incisal edge position,
either in wax or composite. This position
is arrived at by evaluating the patients
maxillary central incisor display with Figure 17On the left of the full-smile photograph, the white line illustrates the desired incisal posi-
the upper lip at rest and in a full smile. tion of the maxillary anterior teeth. On the right is a lip at rest, illustrating that the existing teeth are
The third step is to determine if any 2.5 mm under the upper lip.
alteration to the lingual contour of the
maxillary incisors is necessary, and if
so, to perform that alteration in wax
or composite as well. Essentially, the
desired changes to the maxillary central
incisors have now been transferred to
the model.
The fourth step is to close the artic-
ulator and evaluate the anterior and
posterior occlusions. In some patients Figure 18A view of the patients mounted models. There is severe wear and secondary eruption of
the desired changes to the maxillary the anterior teeth with minimal wear of the posterior teeth.
anterior teeth may be made without a
significant alteration to the anterior or
posterior occlusion. However, in other
patients the changes performed on the
maxillary anterior will result in a pos-
terior open bite when the articulator is
closed. The decision that must be made
is whether the posterior open bite will
be closed by building up the posterior
teeth and therefore opening the vertical Figure 19On the right, the desired alterations for the maxillary incisors have been made in wax.
dimension, or whether the posterior The mandibular incisors were reduced in length until the posterior teeth were in occlusion. The pho-
tograph on the left shows how much the mandibular incisors would need to be shortened to allow for
open bite will be closed by altering the the change in the maxillary anterior teeth with no change in vertical dimension.
mandibular incisors. In many patients
either approach may be successful.
Generally, evaluating which teeth need
restoration guides the clinician as to
whether the lower incisors should be
modified or the posterior teeth built up.
Whenever possible, using the patients
existing vertical dimension makes it
easier for the patient to phase treatment
over time. The fifth step, if necessary,
is to modify the mandibular incisors, Figure 20On the left, the desired changes in the maxillary incisors have been made in wax. The
shortening them until the posterior mandibular incisors have been waxed to a normal length and the articulator has not yet been closed
teeth touch (if that was the ultimate down. On the right, the articulator is now closed until anterior contact occurs. At that point the deci-
sion can be made as to whether the anterior relationship is acceptable or not. If it is deemed accept-
decision). In many cases of severe wear, able, then the incisors have created the new occlusal vertical dimension and the posterior teeth would
lengthening them to avoid the need now be built into contact.

10 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006

 11. Janson GR, Metaxas A, Woodside DG.
Variation in maxillary and mandibular molar
and incisor vertical dimension in 12-year-
old subjects with excess normal and shorter
lower anterior face height. Am J Orthod
Dentofacial Orthop. 1994;106:409-418.
12. Proffit WR, Field HW, Nixon WL, et al. Facial
pattern differences in long-faced children
and adults. Am J Orthod. 1984;85:217-223.
13. Proffit WR, Field HW, Nixon WL. Occlusal
Figure 21These before and after photographs appear to show a significant increase in vertical forces in normal and long-faced children. J
dimension; however, the maxillary anterior teeth have had 4 mm to 5 mm of periodontal crown Dent Res. 1983;62:571-574.
lengthening. Although this patients entire mouth was reconstructed at once, the vertical dimension 14. Fish LC, Wolford LM, Epker B. Surgical
was increased only 1.5 mm because the patient already had excessive overjet. orthodontic correction of vertical maxillary
excess. Am J Orthod. 1978;73:241-257.
15. Cangialosi T. Skeletal morphologic features
of anterior open-bite. Am J Orthod. 1984;
85:28-56.
16. Van Spronsen PH, Weijs WA, Valk J, et al. A
comparison of jaw muscle orientation and
moment arms of long-face and normal
adults. J Dent Res. 1996;75:1372-1380.
17. Bell WH. Correction of the short-face syndrome/
vertical maxillary deficiency; a preliminary
report. J Oral Surg. 1997;35:110-120.
18. Opdebeec H, Bell WH. The short face syn-
Figure 22Before and after photographs illustrate a significant change in appearance, primarily drome. Am J Orthod. 1987;73:499-511.
because of a significant change in tooth display with minimal alteration in vertical dimension.
19. Linder-Anderson S, Woodside DG. Some
craniofacial variables related to small or
for crown lengthening will now estab- does need all of their dentition rehabil- diminishing lower anterior face height.
lish the new vertical dimension to which itated, increasing vertical dimension is Swed Dent J. 1982;15(Suppl):131-146.
20. Wessberg GA, Fish LC, Epker BN. The short-
the posterior teeth will be built. The a perfectly acceptable way of achieving face patient: Surgical-orthodontic treatment
chosen vertical dimension should be a the esthetics and functional results that options. J Clin Orthod. 1982;16:668-685.
combination of the esthetics of the max- are desired. 21. Wessberg GA, Epker BN. Surgical inferior
illary and mandibular incisor incisal edge repositioning of the maxilla: treatment con-
siderations and comprehensive manage-
position, the restorative needs of the References ment. Oral Surg Oral Med Oral Path. 1981;
anterior and posterior teeth, and the 1. The Enigma of the Vertical Dimension.
Published in 2000 by the Center of Human 52:349-356.
desired functional needs of overbite and Growth and Development, The University 22. Brodie AG. On the growth pattern of the
overjet. It is arrived at on the articulator of Michigan. human head from the third month to the
eighth year of life. Am J Anat. 1941;68:
through trial and error, while balancing 2. Bjork A, Skieller V. Facial development and
tooth eruption. Am J Orthod. 1972;62: 209-262.
all the previous factors as well as attempt- 339-383. 23. Ingervall B, Thilander B. Relation between
ing to do what is in the best interest of 3. Bjork A. Skieller V. Normal and abnormal facial morphology and activity of the masti-
the patient. It is the adaptability of growth of the mandible: a synthesis of lon- catory muscles: An electromyographic and
gitudinal cephalometric implant studies radiographic cephalometric investigation.
patients to alterations in vertical dimen-
over a period of 25 years. Eur J Orthod. J Oral Rehab. 1974;1:131-147.
sion that allows us to take this approach 1983;5:1-46. 24. Thompson IL, Kendrick GS. Changes in the
to treatment rather than to believe that 4. Sassouni V. A classification of skeletal facial vertical dimension of the human male skull
only one vertical dimension can be types. Am J Orthod. 1969;55:109-123. during third and fourth decades of life. Anat
5. Beckmann SH, Kuitert RB, Prahl-Anderson Rec. 1964;150:209-214.
acceptable (Figures 16 through 22). B, et al. Alveolar and skeletal dimensions 25. Tallgren A. Changes in adult face height
associated with overbite. Am J Orthod
due to aging, wear and loss of teeth and
Conclusion Dentofacial Orthop. 1998;113:443-452.
prosthetic treatment. Acta Odontol Scand.
6. Beckmann SH, Kuitert RB, Prahl-Anderson B,
There are multiple acceptable ver- et al. Alveolar and skeletal dimensions asso-
1957;15(Suppl 24):1-12.
tical dimensions at which patients can 26. Proffitt WK, Vig KW. Primary failure of erup-
ciated with lower face height. Am J Orthod
tion; a possible cause of posterior open-bite.
be treated, therefore, using vertical Dentofacial Orthop. 1998;113:498-506.
Am J Orthod. 1981;80:173-190.
7. Nanda SK. Growth patterns in subjects with
dimension as a sole justification for 27. Gierie WV, Paterson RL, Proffit WR. Response
long and short faces. Am J Orthod Dento-
treatment is not supported. In addition, facial Orthop. 1990;98:247-258. of eruption human premolars to force appli-
if the patients posterior teeth are 8. Nanda SK. Patterns of vertical growth in cation. Arch Oral Biol. 1999;44:423-428.
the face. Am J Orthod Dentofacial Orthop. 28. Kahn J, Tallents RH, Katzberg RW, et al.
unworn and in occlusion, virtually all Association between dental occlusal vari-
1998;93:103-116.
patients can be treated at their existing 9. Richardson A. Skeletal factors in anterior able and intraarticular temporomandibular
vertical dimension if they are willing open and deep bite. Am J Orthod. 1969; joint disorders; horizontal and vertical over-
to consider orthodontic movement of 56:114-127 lap. J Prosthet Dent. 1998;79:658-662.
10. Brodie AG. On the growth pattern of the 29. Rivera-Morales WC, Mohl ND. Relationship
their anterior teeth or crown length- of occlusal vertical dimension to the health
human head from the third month to the
CE

ening and restoration of their anterior eighth year of life. Am J Anat. 1941;68: of the masticatory system. J Prosth Dent.
teeth. At the same time, if a patient 209-262. 1991;65:547-553.

Vol. 2, No. 3, 2006 Advanced Esthetics & Interdisciplinary Dentistry 11

30. Kovaleski WC, DeBoever J. Influence of occlusal obtained by a combined orthodontic/ 65. Benediktsson E. Variation in tongue and jaw
splints on jaw positions and musculature in prosthetic approach. J Oral Rehabil. 1985; position in S sound production in relation
patients with temporomandibular joint dys- 12:173-176. to front teeth occlusion. Acta Odontol Scand.
function. J Prosthet Dent. 1975;33:321-327. 48. Ismail YH, George WA, Sassouni V, Scott RH. 1958;15:275-303.
31. Manns A, Miralles R, Santander H, Valdivia Cephalometric study of the changes occur- 66. Atwood DA. A critique of research of the
J. Influences of the vertical dimension in ring in the face height following prosthetic rest position of the mandible. J Prosth Dent.
the treatment of myofacial pain-dysfunc- treatment. I. Gradual reduction of both 966;16:848-854.
tion syndrome. J Prosthet Dent. 1983;50: occlusal and rest face heights. J Prosthet 67. Babu CL, Singh S, Rao SN. Determination of
700-709. Dent. 1968;19:321-330. vertical dimension of rest. A comparative
32. Christensen J. Effect of occlusion-raising 49. Ismail YH, Sassoun I V. Cephalometric study study. J Prosthet Dent. 1987;58:238-245.
procedure on the chewing system. Den of the changes occurring in the face height 68. Garnick J, Ramfjord SP. Rest position-an
Pract Dent Rec. 1970;20:233-238. following prosthetic treatment. II. Variability
electromyographic and clinical investiga-
33. Carlsson GE, Ingervall B, Kocak G. Effect of in the rate of face height reduction. J Prosthet
tion. J Prosth Dent. 1962;12:895-911.
increasing vertical dimension on the masti- Dent. 1968;19:331-337.
catory system in subjects with natural teeth. 69. Feldman S. Rest vertical dimension deter-
50. Tallgren A. The continuing reduction of the
J Prosth Dent. 1979;41:284-289. mined by electromyography with biofeed-
residual alveolar ridges in complete denture
34. Kohno S, Bando E. Functional adaptation of back as compared to conventional methods.
wearers: a mixed-longitudinal study covering
masticatory muscles as a result of large J Prosth Dent. 1978;84:216-219.
25 years. J Prosthet Dent. 1972;27:120-132.
increases in the vertical dimension. Desch 70. Atwood DA. A cephalometric study of the
51. Forsberg CM, Eliasson S, Westergren H.
Zahnarzt. rest position of the mandible. Part I. J Prosth
Face height and tooth eruption in adults-a
35. Rugh JD, Johnson RW. Vertical dimension dis- Dent. 1956;6:504-519.
20-year follow-up investigation. Eur J Orthod.
crepancies and masticatory pain/disfunction. 71. Rugh JD, Drago CJ. Vertical dimension; A
1991;13:249-254.
In: Abnormal Jaw Mechanics. Solberg WKC, study of clinical rest position and jaw mus-
52. Dahl BL, Krogstad O. The effect of a partial
ed. Chicago: Quintessence. 1984:117-133. cle activity. J Prosth Dent. 1981;45:670-675.
bite raising splint on the occlusal face height:
36. Sions DG, Mense S. Understanding and 72. Thompson JR. The rest position of the
An x-ray cephalometric study in human
measurement of muscle tone as related to mandible and its application to analysis and
adults. Acta Odontol Scand. 1982; 40:17-24.
clinical muscle pain. Pain. 1998;75:1-17. correction of malocclusion. Angle Orthod.
53. Manns A, Miralles R, Guerrero F. The changes
37. Tryde G, Stoltze K, Morimoto T, Salk D.
in electrical activity of the postural muscles 1949;19:162-187.
Long term changes in the perception of
of the mandible upon varying the vertical 73. Thompson JR. The rest position of the
comfortable mandibular occlusal positions.
dimension. J Prosthet Dent. 1981;45:438-445. mandible and its significance to dental sci-
J Oral Rehabil. 1977;4:9-15.
54. Michekatti A, Farella M, Vollaro S, Martina ence. J Am Dent Assoc. 1946;33:151-180.
38. De Boever JA, Adriaens PA, Seynhaeve TM.
R. Mandibular rest positions and electrical 74. Fish F. The functional anatomy of the rest
Raising the vertical dimension of occlusion
activity of the masticatory muscles. J Prosthet position of the mandible. Dent Pract Dent
with fixed bridges (abstract). J Dent Res.
1989;68:902. Dent. 1997;78:48-53. Rec. 1961;11:178-188.
39. Hellsing G. Functional adaptation to 55. Miles TS, Poliakov AV, Nordstrom MA. 75. Gross MD, Ormianer Z. A preliminary study
changes in vertical dimension. J Prosthet Responses of human masseter motor units on the effect of occlusal vertical dimension
Dent. 1984;52:867-870. to stretch. J Physiol. 1995;483:251-264. increase on mandibular postural rest posi-
40. Maxwell LC, Carlson DS, McNamara JA, 56. Carr AB, Christensen LV, Donegan SJ, Ziebert tion. Dent Pract Dent Rec. 1961;11:178-188.
Faulkner JA. Adaptation of the masseter and GJ. Postural contractile activities of human 76. Ormianer Z, Gross M. A 2-year follow-up of
temporalis muscles following alteration in jaw muscles following use of an occlusal mandibular posture following an increase in
length with or without surgical detach- splint. J Oral Rehabil. 1991;18:185-191. occlusal vertical dimension beyond the clin-
ment. Anat Rec. 1981;200:127-137. 57. Manns A, Miralles R, Palazzi C. EMG, bite ical rest position with fixed restorations. J
41. Wessberg GA, ORyan FS, Washburn MC, force, and elongation of the masseter mus- Oral Rehabil. 1998;25:877-883.
Epker BN. Neuromuscular adaptation to cle under isometric voluntary contractions 77. Lund P, Nishiyama T, Moller E. Postural
surgical superior repositioning of the maxilla. and variations of vertical dimension. J
activity in the muscles of mastication with
J Maxillo Surg. 1981;9:117-122. Prosthet Dent. 1979;42:674-682.
the subject upright, inclined, and supine.
42. Hoppenreijs RJM, Freihofer HPM, Stoelinga 58. Morimoto T, Abekura H, Tokeyama H,
Scand J Dent Res. 1970;78:417-424.
PJW, et al. Skeletal and dento-alveolar stability Hamada T. Alteration in the bite force and
78. Lee RL. Esthetics and its relationship to func-
of Le Fort I: intrusion osteotomies and bimax- EMG activity with changes in the vertical
tion. In: Fundamentals of Esthetics. Refenauct
illary osteotomies in an anterior open bite dimension of edentulous subjects. J Oral
CR, ed. Quintessence.
deformities: a retrospective tree-centre study. Rehabil. 1996;23:336-341.
79. Dumont TD. The Ideal Biologic Dental Model.
Int J Oral Maxillofac Surg. 1997;26:161-175. 59. Lindauer SJ, Gay T, Rendell J. Effect of jaw
OBI Foundation for Bioesthetic Dentistry.
43. Bailey LJ, Phillips C, Proffit WR, Turvey TA. opening on masticatory muscle EMG-force
Rev. 2004.
Stability following superior repositioning of characteristics. J Dent Res. 1993;72:51-55.
60. Nakamura T, Inoue T, Ishigaki S, Maruyama 80. Murphy T. Compensatory mechanisms in
the maxilla by LeFort I osteotomy: five year
T. The effect of vertical dimension change facial height adjustments to functional tooth
follow-up. Int J Adult Orthod Orthodnath
Surg. 1994;9:163-174. on mandibular movements and muscle attrition. Aust Dent J. 1959;4:312-323.
44. Bell WH, Scheidman GB. Correction of verti- activity. Int J Prosthodont. 1988;1:297-301. 81. Rifkin R. Facial analysis: A comprehensive
cal maxillary deficiency; stability and soft tis- 61. Hammond RJ, Beder OF. Increased vertical approach to treatment planning in aesthet-
sue changes. J Oral Surg. 1981;39:666-670. dimension and speech articulation errors. J ic dentistry. Pract Periodontics Aesthet Dent.
45. Quejada JG, Bell WH, Kawamura H, Zhang Prosthet Dent. 1984;52:401-406. 2000;12:865-871.
X. Skeletal stability after inferior maxillary 62. Howell PG. Incisal relationship during speech. 82. McLaren EA, Rifkin R. Macroesthetics: facial
repositioning. Int J Adult Orthodon Orthognath J Prosthet Dent. 1986;56:93-99. and dentofacial analysis. J Calif Dent Assoc.
Surg. 1987;2:67-74. 63. Howell PG. The variation in the size and 2002;30:839-846.
46. Ellis E III, Carlson DS, Frydenlund S. Stability shape of the human speech pattern with 83. Gross MD, Nissan J, Ormianer Z, et al. The
and midface augmentation; an experimen- incisor tooth relation. Arch Oral Biol. 1987; effect of increasing occlusal vertical dimen-
tal study of musculoskeletal interaction and 32:587-592. sion on face height. Int J Prosthodont. 2002;
fixation methods. J Oral Maxillofac Surg. 64. Stoller D. Mass examinations of the smallest 15:353-357.
1989;47:1062-1068. vertical dimension during speech in 2000
47. Dahl BL, Krogstead O. Long term observa- persons. Scweiz Mschr Zahnbeilk. 1969;79:
tions of an increase occlusal face height 735-751.

12 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006

 Continuing Education Quiz
Loma Linda University School of Dentistry provides 1 hour of Continuing Education credit for this article for those
who wish to document their continuing education efforts. To participate in this CE lesson, please log on to
www.aegisce.net/aeid, where you may further review this lesson and test online for a fee of $14.00. To obtain
mailing instructions or for more information, please call 877-4-AEGIS-1.

1. Which of the following factors does not affect 7. Problems with speech after a change in vertical
occlusal vertical dimension during growth and dimension are often corrected after an adapta-
development? tion period of how long?
a. growth of the ramus a. 1 week
b. gonial angle of the maxilla b. 10 days
c. gonial angle of the mandible c. 2 to 4 weeks
d. eruption of the teeth d. 6 to 8 weeks
2. Treatment of vertical dimension in patients 8. Most dental schools advise how much of
with a long ramus often involves which of freeway space as normal?
the following? a. 1 mm to 2 mm
a. double jaw surgery b. 2 mm to 4 mm
b. single jaw surgery c. 4 mm to 6 mm
c. orthodontic treatment d. 6 mm to 8 mm
d. none of the above
9. Which of the following is not a method of
3. Dentists commonly alter vertical dimension determining vertical dimension?
in order to: a. use of freeway space
a. improve esthetics b. use of trial appliances
b. improve occlusal relationships c. TENS
c. gain space for the restoration of short or d. method of tooth proportion
worn teeth
10. In a study evaluating whether dentists were
d. all of the above
capable of seeing the facial differences caused by
4. When vertical dimension is increased, resting changes in vertical dimension, the differences
muscle activity level does which of the following? were not seen until the change had reached
a. increases until there is approximately which of the following measurements?
10 mm to 12 mm of anterior vertical opening a. 2 mm
b. decreases until there is approximately b. 4 mm
10 mm to 12 mm of anterior vertical opening c. 6 mm
c. decreases until there is approximately d. 8 mm
7 mm to 9 mm of anterior vertical opening
d. there is no change
5. Resting muscle activity level returns to levels
close to pretreatment levels when vertical
change has been maintained for how long?
a. 1 month to 2 months
b. 3 to 4 months
c. 6 to 8 months
d. 10 to 12 months
6. Practitioners are sometimes concerned with
how a change in vertical dimension will affect
the patients speech, particularly sounds using
which letter?
a. L
b. P
c. S
d. T

14 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 3, 2006