Vertical Jaw Relations

Submitted by

Dr Pragati Parasher

M D S II year

Deptt. Of Posthodontics

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 Table of contents

1. Introduction

2. Definition

3. Significance of vertical dimension

4. Diagnosis of loss of vertical dimension

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Definition –it is the relation of the mandible to the maxilla in vertical
dimension.

The length of the face as determined by the amount of separation of jaws–

GPT 8

 In all the dentulous individuals the teeth act as a vertical stop to the
movement of the mandible when the mouth is closed.
 The muscles & the ligaments attached to the mandible act as a
vertical stop to the movement of the mandible during mouth opening.
 When all the natural teeth are lost, the vertical stop to the mandible,
during closure of the mouth is lost.
 As long as the muscles and the ligaments attached to the mandible
function normally, the vertical stop of the mandible during mouth
opening functions normally.
 That is the limit of the mandible in a verticle direction during wide
opening of the mouth remains constant for any individual as long as
the muscles, the ligament the joints the CNS function normally.

 Mandible assumes two position in the direction & gives 2

measurement or dimensions

(1) vertical dimensions at rest position (VDR)

(2) vertical dimension at occlusion position (VDO)

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SEQUELAE OF TOOTH LOSS:

Due to physiologic (aging) or pathologic conditions loss of teeth occurs. Once

the teeth are lost the alveolar bone which was previously supporting the teeth
starts resorbing. Due to this, the space between the maxilla and mandible
increases and this forces the patient to bring the mandible forward and close. So
the vertical dimension of that patient reduces once the teeth are lost.

METHODS TO RECORD VERTICAL DIMENSION:

MECHANICAL METHODS

1. RIDGE RELATION

a. Distance of incisive papilla from the mandibular incisors

b. Parallelism of the ridges

2. MEASUREMENT OF FORMER DENTURES

PRE-EXTRACTION RECORDS

1. PROFILEX—RAY

2. X-RAY OF POSITION OF CON DYLE HEAD

3. PROFILE PHOTOGRAPH

4. CONTOURED WIRE
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 5. PLASTER CASTS OF TEETH IN OCCLUSION

6. FACIAL MEASUREMENT - WILLIS GAUGE

7. SWENSON'S ACRYLIC FACE MASK

8. DAKOMETER

9. TURNER'S CUT-OUT METHOD

PHYSIOLOGIC METHODS

1. PHYSIOLOGIC REST POSITION

2. PHONETICS AND ESTHETICS AS GUIDES

3. SWALLOWING THRESHOLD

4. TACTILE SENSE

OTHER METHODS AND THEORIES USED PREVIOUSLY

1. PARK'S THEORY

2. BOOS BIMETER

MECHANICAL METHODS: RIDGE RELATION:

 The incisive papilla is used to measure the patient's vertical dimension.

The incisive papilla is a stable landmark and is changes little by residual
alveolar resorption. The distance from the incisive papilla to the incisal
edges of mandibular anterior teeth on the diagnostic casts averages
approximately 4mm in normal dentition. The incisal edge of the maxillary
central incisors are approximately 6mm below the incisive papilla.

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 Therefore the average vertical overlap of the opposing central incisors is
about 2mm.
 Sears, suggested paralleling of maxillary and mandibular jaws, plus a 5
degree opening in the posterior region often gives a chance to correct the
amount of jaw separation. The paralleling is natural because the teeth in
normal occlusion leave the residual ridges in the posterior region parallel
to each other, provided that there has not been an abnormal amount of
changes in the alveolar process. Since clinical crowns of anterior and
posterior natural teeth approximately the same length, their removal
would leave the residual ridges nearly parallel. This would be ideal from
mechanical standpoint, because the denture would not slip anteriorly or
posteriorly. However in most cases, teeth are lost at different times and so
by the time patient becomes edentulous, the ridges are no longer parallel.
In addition the edentulous ridges of maxilla and mandible become more
progressively different in width.

MEASUREMENT OF FORMER DENTURES:

Denture that the patient has been wearing can be measured and the
measurements can be correlated with observations of the patient's face to
determine the amount of changes required. The denture is measured using a
boley's gauge between maxillary and mandibular denture borders. If
measurements of patient's face indicate that this distance is less then
corresponding changes can be made in new denture.

PRE-EXTRACTION RECORDS: PROFILE X-RAY:

Profile x-rays require special equipment that is not very practical and is
seldom used, but is mentioned as one of the possible methods.

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Profile radiographs of the face may be used, but problem of establishing
vertical relation of the rest position and enlargement of the image cause
some inaccuracies.

X-RAYS OF THE POSITION OF CONDYLE HEADS:

Gray, Hanau & McCollum said that the head of the condyle does not
immediately leave the glenoid fossa when the opening movement is started
and therefore x-ray position of condyle would be considered unreliable.

PROFILE PHOTOGRAPHS:

WRIGHT(1939) wrote that a suitable photograph can be an aid to the

establishment of the vertical dimension. He measured the distance between
the pupils, and the distance from the eyebrow to the lower border of the
chin on the photograph. On the patient, he measured the interpupillary
distance. Then he set up a proportional relation of the photograph to the
patient using the interpupillary distance and applied this proportion to
brow-chin distance.

Interpupillary distance of photograph = brow- chin distance of the

photograph Patient's interpupillary distance patient's brow-chin distance

LEAD WIRES:

Soft lead wire has often been used to outline the contour of the face before
extraction of the teeth. This contoured wire is outline on a piece of
cardboard and cut out to be refitted to the patient's face at the time of
determine the vertical dimension. This method is full of pitfalls because it is

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impossible to shape a wire accurately against soft tissues without producing
distortion

CASTS OF TEETH IN OCCLUSION:

This is a simple way of recording the vertical overlap relation, the size and
shape of the teeth. The casts should mounted on the articulator. The casts
serve as an indication of the amount of space required between the ridges
for the teeth of this size.

FACIAL MEASUREMENTS:

Many devices have been used in many different forms to measure

[Link] have been made to record the relation of the head to the
central incisors vertically and antero - posteriorly by placement of a
facebow with auditory meatus plugs in position with spectacle suspension.
Another method is to measure the distance from the base of the nose to the
chin by means of pair of dividers before the teeth are extracted.

WILLIS DEVICE: Another method is use of a pair of callipers to find the

distance from the undersurface of the chin to the base of the nose. It is
developed by willis as an aid in determining vertical dimension. The
technique suggested that, with the adjusted record rim or finished denture
inside the mouth the distance from the base of the nose to the lower edge of
the mandible to be measured, which should be equal to the distance from
the pupil of the eye to rima oris or parting line of the lips. SWENSON
found this technique is helpful in patient who have all the natural teeth in
good condition, but for patients who have lost teeth and are edentulous for
long time, the facial height decreases and the rima oris is almost close to the

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nose. In that case the occlusal rims have to be lengthened more than 6 or 7
mm to bring the lip to normal position which is not advisable.

ACRYLIC FACE MASK:

SWENSON (1959) suggested a method called "Acrylic face mask". This

method is a three dimensional registration of the vertical dimension. This
idea of this method is to make facial record and make a stone cast and then
produce transparent face form that will be an exact guide for reproduction
of the vertical dimension and will show the fullness or lack of fullness of
the face by enabling the operator to see through transparent form and note
the areas of contact or lack of contact. In this method, Swenson used
Negocoll, reversible hydrocolloid. Carefully the impression material is
applied over the patient's face from hair line, well over the chin and back to
ears. Two brushes are used to apply the material to the face. One 3/4 inch
brush is used for larger surfaces and a 1/4 inch brush is used around the
nostrils, so as to carry an excess of the material to these more exacting
areas. Two layers of the impression were coated and the thickness of
material does not have to be exact, but should be near one-quarter inch in
depth. The impression is plaster of paris, which is carried by means of
gauze that has been dipped in soft quick setting plaster. Stone cast is
prepared. An outline is drawn over an area around the lower part of the face
cast, which includes the tip of the nose and the under border of the chin and
which extends laterally to the anterior portion of the cheek bones. Then an
acrylic face mask is created with transparent acrylic. This transparent guide
should enable the dentist to reposition the denture supporting structures so
that the patient suffers no loss of facial contour. A strip of casting wax is
luted to the face cast over the cheek and mouth region. Stone model is
poured. The stone model is flasked then transparent acrylic
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DAKOMETER:

TURNER'S CUT-OUT METHOD: (JPD 1969:21:364-70)

Turner developed a "cut-out method" using a simple pantograph. A

headstrap holds the tracing card in a supporting frame close to the median
line of the face. The pantograph pointer is brushed against the facial
contour of the patient which slides back and forth along the facial contour
and up and down along the supporting frame. A pencil is attached to th e
pointer and the pointer automatically traces the profile on the card as the
pointer is moved over the patient's midsagittal plane. Then the pointer is
lowered to a level of incisal edge of maxillary central incisor and a
horizontal line is drawn on the cardboard to indicate the length of the
incisors. Then the traced card is removed and cutback is carried out and the
template is tried on the patient's face and from the labioincisal edge of the
maxilla ry central incisor a cross mark is placed over the previous
horizontal line. (to position the incisal edge of artificial teeth)

A pair of maxilla-mandibular impression were made before extraction of

the teeth, one with irreversible hydrocolloid and other with rubber base
material. Former is used for diagnostic cast and latter is preserved for post
extraction record.

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This profile record registers two anatomical landmark which remains constant
regardless of aging or resorption. They are fore-head-nasal bone region and
inferior border of the mandible. Then with the help of the template the maxillary
occlusal rim is adjusted till it achieves a labial contour which is exactly 30mm
from the cross mark on the template. Similarly the length of the maxillary
occlusion rim is adjusted to the line that indicates the incisal length on the
template.

This occlusion rims when mounted on an articulator will provide

1. Length and the anterior position for maxillary central incisors

2. Arch form

3. Vertical dimension

4. Horizontal overlap 5. Centric relation.

PHYSIOLOGIC METHODS: PHYSIOLOGIC REST POSITION TESTS:

This method is not an exact guide to determine vertical dimension, but it is an aid
along with other methods. A suggested method is to obtain a relaxed state of the
patient when the wax occlusion rims are in place, with the trunk upright and the
head unsupported. After insertion of the occlusal rims into the patient's mouth, the
patient is asked to swallow and let the jaw relax. After relaxation is obvious to the
dentist, the lips are carefully parted to see how much space is present between the
occlusion rims. The patient must allow the dentist to separate the lips without
moving the jaws. This interocclusal distance at rest position should be between 2
and 4 mm in premolar region.

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NISWONGER (1934) defined, the rest position as a neutral position of the
mandible when the opening and closing muscles are in a state of equilibrium. He
suggested a method in which the patient is seated in a position, where the patient's
ala -tragal line is parallel to the floor, then two mraks are made one on the upper
lip and other on the chin, then the patient is asked to swallow and relax, the
distance between the marks are recorded to find the interarch distance. The
disadvantage of this method is that the marks on the skin moved. So Niswonger
advised placement of small red tattoo over the skin to record the interarch space
and rest position, which was not accepted by many of the patients. The interarch
distance recorded in Niswonger's method, when the occlusion rims come in contact
is about 4/32 inch less than original values. This is 1/8 inches average freeway
space falls within 2-4mm which is often advocated. So this technique is reasonably
reliable. If the interarch space is greater then 4mm, the occlusal vertical dimension
is considered to be too small. If the space is less than 2mm, the occlusal vertical
dimension is too great. The occlusal rims are then adjusted accordingly. It is
important to have adequate interocclusal distance, when the mandible is in
physiologic rest position .(SHARRY)

[Link] (JPD 1965;15:851-6) came with a concept called "OPEN

REST CONCEPT". This study has three objectives

1) to investigate the relationship of the corner of the mouth as a soft tissue

landmark of reference to the posterior occlusal plane of the upper and lower teeth
when the mandible is in an "open rest" position, and when the patient is sitting
upright. The open rest position is an unstrained mouth -breathing position with
minimal lip separation. It is a position in which the dentist can observe or obtain a
mental picture of the mesial marginal ridge of the upper and lower first bicuspid
teeth in relation to the commissure of the lips. The development of an adequate

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vertical height in the upper and lower occlusal rims may provide the patient with
the required interocclusal distance.

2) to analyze by cephalometric roentgenography the "open rest technique"

3) to evaluate the relationship of the corner of the mouth to the upper and lower
occlusal planes in complete dentures with the mandible in an "open rest position" .
Cephalogram is made.

The relationship of the corner of the mouth to the upper and lower occlusal planes
in dentitions with one lateral cephalometric roentgenogram which was made for 50
male patients (25-60yrs) with natural teeth. A thin lead foil strip was attached
along the masticatory groove from the mesial marginal ridge of the first bicuspid
tooth to the distal marginal ridge of the second biscuspid tooth of both arches on
the side next to the roentgenogram. Then a thin lead foil strip is adapted over the
skin parallel to the other lead strips on the side next to the roentgenogram.
Roentgenogram were exposed and developed. Tracing of each cephalogram were
made on matte cellulose acetate paper. Parallel lines were drawn through the
shadows of the lead foil which represented the corner of the mouth, the upper
occlusal plane, and the lower occlusal plane. A line was perpendicular to the
occlusal plane from the region of the upper first bicuspid tooth. The intersections
of the perpendicular line with the lines representing the upper occlusal plane, the
commissure and the lower occlusal plane are designated respectively.
Measurement were made along this perpendicular line to determine results. The
upper occlusal plane in the area of the first bicuspid tooth was 1 to 5mm. Above
the commsissure of the lips in open rest position. For clinincal purposes, a point
3mm, above the commissure of the lips was selected as the starting level for the
development of the vertical height of the upper occlusion rim. The lower occlusal

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plane was from 0-4mm. For clinical work, a level 2mm below commissure of the
lips was chosen as the approximate height to which the lower occlusion rim.

Cephalometric evaluation of the open rest technique was done by making lateral
cephalograms with natural teeth in centric occlusion. Then extractions are carried
out and 3 months later complete denture were constructed. Vertical dimension of
occlusion was developed by shaping upper occlusal rim to support upper in
anterior region and height of the rim in first bicuspid region was formed about
3mm above the corner of the mouth in the open rest technique. Lower rim was
constructed 2mm below the commissure of the lips in open rest position. Centric
occlusion having been established and during insertion of denture lateral
cephalogram was made with teeth in centric occlusion. Serial tracing were made of
pre-extraction and denture insertion cephalograms. Landmarks like ANS,
BOLTON'S POINT, SELLA TURCICA, NASION, LINE FROM NASION TO
BOLTON"S POINT and A PERPENDICULAR LINE FROM
SELLATURCICATOTHE LINE FROM BOLTON'S POINT THE NASION. A
facial line was drawn from the nasion tangent to the symphysis and a mandibular
line was drawn to intersect the facial line tangent to the lower border of the
mandible. The intersection is designated as (O). Plus or minus measurement of this
line in the postinsertion cephalogram was compared withthe pre-extraction
cephalogram and was used to determine the relative accuracy of the method.
Clinically a deviation of plus or minus 1mm from the pre-extraction dimension
was considered to be correct in the completed dentures. Results obtained by this
technique are better compared with vertical dimension measure using physiologic
rest, tactile muscle sense and swallowing methods.

Relationship of corner of the mouth to the upper and lower occlusal planes in
complete dentures was studied using Cephalometric evaluation of the open rest

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technique and it has been found that development of the upper occlusal plane
approximately 3 mm above the commissure of the lips, and the lower occlusal
plane approximately 2 mm, below the commissure of the lips will provide an
adequate vertical dimension of occlusion

LARKIN (1967) developed a device in which wires attached to the upper and the
lower occlusion rims emerge from the corners of the mouth and are positioned over
a millimetre scale. When the patient closes into vertical dimension of occlusion the
readings are made on the scale. Then the patient is induced to assume mandibular
rest position and readings are made. The difference between the two readings gives
interocclusal distance.

LANGER AND MICHMAN (1969) modified larkin's device to avoid the wires
emerging out of the mouth. Instead they fixed the gauge to the upper occlusion rim
itself. These devices proved more accurate measurements than measuring reference
points on the face.

PHONETICS:

Phonetic theory is based upon a correlation of the interoc clusal distances, the
position of the occlusal plane and the position of the tongue relative to the
occlusion rims or teeth. The most popular sound used as an aid in determining the
rest position is the labial "M" sound which can be said without the use of the
teeth. However the M sound often leaves lips in contact. As soon as the dentist
tries to part the lip to visualize the interocclusal distance the mandible drops down
and dimension is lost. To overcome this the M sound was extended to "emma"
sound followed by labial "P" sound which leaves the lip apart, this is how the
word "MISSISSIPPI" became popular.

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Phonetic tests of the vertical dimension include listening to speech sound
production and observing the relationships of the teeth during speech. The
production of ch, 5 & J sounds brings the anterior teeth close together. When
correctly placed, the lower incisors should move forward to a position nearly
directly under and almost touching the upper incisors. If the distance is too large, it
means that too small vertical dimen sion of occlusion may have been established.
If the anterior teeth touch when these sounds are made than the vertical dimension
is probably too great. Likewise, if the teeth click together during speech, the
vertical dimension is probably too great. (BOUCHER 12TH edition)

SILVERMAN(1955) suggested that vertical dimension can be measured using

closest speaking space, which is usually not same as the freeway space. The
method states, the occlusion rims are placed in the mouth and the height is adjusted
until a minimum of 2mm of space exists when the patient pronounces the letter
"5". Silverman points out that the closest speaking space may vary from 0 to
10mm in different persons, but 2mm average will prevent an increase in the
vertical dimension.

ESTHETICS:

The vertical relation of the mandible to the maxilla also affects esthetics. A study
of the skin of the lips compared with the skin over other parts of the face can be
used as a guide. Normally the tone of the facial skin should be the same
throughout. Ho wever, it must be realized that the relative anteroposterior positions
of the teeth are atleast equally as involved in the vertical relations of the jaws as in
the restoration of the skin tone. The contour of the lips depends on their intrinsic
structure and the support behind them. Therefore the dentist must initially contour
the labial surface of the occlusion rims so they closely simulate the antero-

16
posterior tooth positions and the contour of the base of the denture. This contoured
surface must replace or restore the tissue support provided by the natural
structures. If the lips are not supported anteriorly, they will be more nearly vertical
than when supported by natural tissues. In this sit uation the tendency to increase
the support for the lips increases the vertical dimension of occlusion and thus it
leads to increased lower facial height. The esthetic guide to arrive at appropriate
vertical dimension is to select the teeth which is of same size as the natural teeth
and to estimate the amount of tissue lost from the alveolar ridges. This technique is
relatively unreliable one.

SWALLOWING THRESHOLD:

The position of the mandible at the beginning of the swallowing act has been used
as a guide to the vertical dimension of occlusion. The theory is that the teeth come
together with a very light contact at the beginning of the swallowing cycle. If
denture occlusion is continually missing during swallowing, the dimension of
occlusion may be in sufficient. On this basis, a record of the relation of the two
jaws at this point in the swallowing cycle is used as an indicator of the vertical
dimension of occlusion. The technique involves building of wax cones on the
lower denture base in such a way that they contact the upper denture when jaws are
open too wide. Then the salivary flow is stimulated by candy, the repeated
swallowing of the saliva will gradually reduce the height of the wax cones to allow
the mandible to reach the level of the vertical dimension of occlusion.
Disadvantage of this method is inconsistency of the results.

SHANAHAN(1956) indicated that the mandibular pattern of the movement during

deglutition is the same for the edentulous infants as it is for edentulous adults. He
maintained that the eruption of teeth to the occlusal plane is by the act of

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swallowing which establishes the vertical dimension of occlusion. When
constructing the denture the advocates of swallowing technique believe that soft
wax on the occlusion rim is reduced during deglutition to give the correct vertical
dimension of occlusion.

ISMAIL AND GEORGE(1968) checked the swallowing method by using

cephalometric radiographs to record the vertical dimension of occlusion before the
teeth were extracted and after the denture were inserted. The swallowing technique
produced an increase of 0 - 5mm (mean 2.8mm) in vertical dimension of occlusion.
They found that the increase in dimension is directly proportional to the number of
teeth missing before extraction of teeth.

FINNEGAN(1967) developed a device to record the force generated during

swallowing. This device consisted of an intraoral hydraulic system with a
resistance strain gauge connected through a bridge circuit to a recorder. The strain
gauge responded to force exerted upon it by an alteration in its resistance which
caused an unbalanced circuit of the bridge. The unbalanced voltage was amplified
and recorded. The deflections recorded were converted back to their respective
pressure values by a known calibration of pressure, which then was applied to the
measuring device. Graphs were constructed from the calibrati on recordings to
convert millimeters of pen deflection to grams of force. But he was unable to
establish a relationship between the force exerted between the teeth on swallowing
and the vertical dimension.

TACTILE SENSE AND PATIENT PERCEIVED COMFORT:

Patient's tactile sense can be used as a guide for determination of occlusal vertical
dimension. With this method, an adjustable central bearing screw is attached to one
of the occlusion rims, and a central bearing plate is attached to the other rim.

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Central bearing screw is adjusted so that it is too long, then progressively the screw
is adjusted downward till the patient indicates the jaws are closing too far. This
procedure is then repeated in the opposite direction till the patient indicates that the
teet h feels too long. The screw is then adjusted downward till the patient feels
comfortable. Disadvantage of this method is patient's precipitation in the decision
to establish a vertical dimension record should be considered, however because
there are both physiological and psychological advantages to this approach.

OTHER METHODS:

PARK'S THEORY OF DETERMINING VERTICAL DIMENSION:

Park believed that the condyle travelled forward towards the em inentia
simultaneously with the start of the opening movement of the mandible, when first
slight separation of the teeth occurs and he could record the exact vertical
dimension at that position. According to Parks, the mandible opens on a rotational
center which is away from the head of the condyle that is below and behind the
angle of the mandible. This rotation center is held until the former occlusal plane is
reached and then, upon further closure, rotates around the head of the condyle.
These movements would scribe two different arcs, and the point of intersection of
these two arcs would indicate the correct amount of jaw separation. Practically this
is achieved by placing marks across the bite rims and to note the point at which
these marks failed to coincide.

This theory was found to be incorrect with the practical tests and also with the use
of kinematic facebow which proves the concept given by HANAU, GRAY AND
McCOLLUM which is, the hinge axis of the mandible is through the condyle
heads for the first part of the opening movement of the mandible.

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VERTICAL DIMENSION DETERMINATION BY MEANS OF POWER
POINT:

RALPH BOOS came up with his invention of a device that will register the biting
force at varying degrees of jaw separation. The theory is that the patient registers
the maximum amount of biting force when the teeth first contact in centric
occlusion. This theory is based on the premise that the muscles of mastication will
exert their greatest degree of force when their origin and insertion are this exact
distance apart. The device used for this registration is called BIMETER. The
device is set so that the jaws are separated to an excessive degree of opening and
the patient is instructed to bite with all his power . This registers the force on the
dial of the bimeter and a notation of the registration is written on a sheet of paper.
The device is reduced in height by turning the cap two full turns which closes the
bite one and half millimetres. The biting procedure is repeated and the results are
recorded. Recordings are made successively lower levels until t5he increasing
regiostration ahs reached a maximum and a decreases of force registration has set
in.

The cap is adjusted so as to start back again towards a greater degree of opening,
and this procedure is continued until maximum point is again rea ched. While the
patient is biting at this maximum point the lock nut is set, which will hold the
device at this degree of opening. plaster registrations are then taken and the cast is
mounted to this relation. To allow for a freeway space Boos suggested that, when 0
to 50 pounds pressure is exterted bite is reduced to two and one fourth millimetres,
or when force is exerted between 50 to 100 pounds the vertical dimension is
reduced by 3 mm.

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This apparatus may also be used as central bearing point in gothi c arch tracing.
This theory was not accepted by most dentists so BOOS (1952) stated that the
"maximum vertical dimension is the dimension at the rest position or maximum
force, minus 2mm"

DETERMINATION OF VERTICAL DIMENSION BY

ELECTROMYOGRAPHY:

This method is based on the rest position of the mandible. Rest position of the
mandible is identified by electromyography. MOYER'S (1956) prefers the term
postural position of the mandible to rest position of the mandible and he states that
this is a primitive, unlearned position. HICKEY et aI (1957) contend that this
position can be determined by electromyography which would record minimal
activities of the muscle, and they stated that all muscles showed greater activity in
other positions than when the jaws are at rest.

SHPUNTOFF (1956) registered both vertical dimension and centric relation by

electromyographyic means. He concluded that

1. A single channel high gain differential electromyograph operating in an

unshielded room can be used to determine physiologic rest position and centric
position.

1. Centric position has been found in 215 normal adults to produce a

characteristic electromyogra m.

2. The registration of centric position in edentulous patients and others

requiring mandible repositioning is accomplished by the technique of visual feed-
back control. This method allows the patient to place his mandible at the specific

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position and maintain it during registration by watching the electromyographic
patterns.

2. Physiologic rest position is registered in the same manner while the patient
watches and maintains the pattern of electrical silence in the electromyogram.

3. Examination of other muscles of the masticatory mechanism indicates that

when one muscle of the myotatic unit is at physiologic rest, the others are also
silent.

4. The great variety of methods of registering physiologic rest position and

centric position should be studied and compared by the electromyographic
technique.

Although many methods of assessing and recording vertical relations in edentulous

patients have been presented and evaluated. Most of the methods are not the
accurate technique for measurement of vertical dimension. Pre-extraction records,
if available, are better aid in establishing occlusal vertical dimension but when the
pre-extraction records does not exist the dentist must rely on the other methods like
esthetics supplemented by otheraids which are often misleading. So "clinical
judgement" is one way in which dentist does not rely on one method and uses
many methods and establishes the vertical dimension.

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Increased vertical dimension Decreased vertical dimension

Increased trauma to tissues Lesser trauma

Increase lower facial height Decreased

Cheek biting Angular chilitis

Difficulty in speech and swallowing Difficulty in swallowing

Pain and clicking in tmj Pain , clicking and discomfort along

with headache and neuralgia
Streching of facial muscles loss of lip fullness
Loss of muscle tone
Corners of mouth are turned down
Thinning of vermilion borders of lip

Sequalae of alterations in vertical dimensions:

CONCLUSION

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Vertical dimension is the phase of complete denture prosthesis which should be
recorded correctly to regain the lost vertical height of the occlusion. Restoring vertical
dimension is very helpful in restoring esthetics and function. But unfortunately, there is
no measure that tells us the exact point where the mandibular closure; therefore, there is
no proof for most accurate vertical dimension. Compromises between esthetics and
function are often advisable and necessary.

REFERENCES

1. . Swenson MG. Complete Dentures. 2nd edition

2. Boucher's Prosthodontictreatment for Edentulous patients. 9th edition & 12th

edition

3. John [Link]. Complete denture Prosthodontics

4. Alexander [Link]. Mastering the Art of Complete Dentures.

5. Sheldon Winkler. Essentials of Complete denture Prosthodontics. 2nd edition.

6. [Link]. Clinical assessment of vertical dimension. J Prosthet Dent

2006; 96: 79-83.

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7. Thomas [Link]. Physiologic vertical dimension and centric relation. J
Prosthet Dent 2004; 91: 206-9.

8. Irving [Link] & Stephen [Link]. Vertical dimension

measurements. J Prosthet Dent 2006; 95: 175-80.

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