Simplifying Vertical Dimension by Dr. John Nosti

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A step-by-step process on how to increase VDO

by Dr. John Nosti

Introduction
Vertical dimension is one of the most misunderstood aspects of dental rehabilitation. Over the years, there have been many varying opinions on the subject as to when, why and how to change the vertical dimension of occlusion (VDO)—even suggestions that a change is not possible. With so many contradictions on the topic, it is no wonder dentists are confused or feel so intimidated that they avoid it all together. With no shortage of worn dentitions in everyday general practice, this leaves a plethora of patients unhappy with the appearance or functionality of their teeth.

Typing “Vertical Dimension of Occlusion in Dentistry” into Google Scholar pulls up 46,000 results. Reducing the search by years published to 2010–2024 cuts this down to a mere 17,700. Can you sense my sarcasm? Many of these citations discuss or reference the masticatory muscles, the temporomandibular joint, the mandibular posture, rest position, bite raising, occlusal space, hinge position, centric relation, anterior guidance and aesthetics. All these topics are potential issues, so let’s put this into an easy-to-understand, systematic approach.

Vertical dimension of aesthetics
The Glossary of Prosthodontic Terms defines VDO as “the lower facial height measured between two points when the occluding members are in contact.”¹ VDO refers to the vertical position of the mandible in relation to the maxilla when the upper and lower teeth are intercuspated at the most closed position. Although you may have never performed a full mouth rehabilitation or reconstruction with teeth present, most of us have performed a full mouth reconstruction on a fully edentulous patient. Performing removable reconstructions is very similar to performing fixed rehabilitations. The starting point in both disciplines is the maxillary central incisor position. This is one reason why I feel it is more appropriate to call VDO the Vertical Dimension of Aesthetics.

When evaluating patients with worn dentition to determine where the final position of the central incisor should be, previously restored or not, (Figs. 1–2) we must take facial aesthetics into consideration.^{2, 3} I feel a combination of evaluating the patient’s incisor position in both full smile and rest (repose) should be used to determine whether an addition is required (Figs. 3–4). To photograph the patient’s rest position, I find it helpful for the patient to say the word “Emma” and then remain still (Fig. 4). While evaluating the rest position, the central incisor average range is 2–4 mm in repose. However, a study by Carl Misch demonstrated that the range of central incisor display at rest is 0–8 mm⁴ for adults between the ages of 30 to 60 years old. The number of times patients from this study fell into this 2–4 mm average is less than 30 percent. He showed that the canine is a far better landmark to use, and in smile design, the central and canine are on the same plane. Using a 0 mm canine show in repose (plus or minus 1 mm), means the canine positioned just behind the lip will yield a more accurate result of where the central incisor should be positioned.

Fig. 1

Fig. 2

Fig.3

Fig.4

STEP 1: Establish existing measurements of the teeth
When we are assessing a candidate for an aesthetic vertical dimension change, the first step is to measure the existing lengths of the teeth, including overbite, for communication with the lab. The four measurements you want to record are: the existing length of the maxillary central incisor (Fig. 5), the existing length of the mandibular central incisor opposing the maxillary central that you measured (Fig. 6) and the CEJ-CEJ measurement between these two teeth (Fig. 7). Lastly, determine the existing overbite measurement. The CEJ-CEJ measurement is the measurement of the maxillary central plus the mandibular central minus the existing overbite. For the patient featured in these figures the maxillary central incisor length is approximately 7 mm, the mandibular central incisor length is also approximately 7 mm. The existing CEJ-CEJ measurement is 11 mm, showing us this patient has a 3 mm overbite. These measurements will be used moving forward in communication with the lab to confirm the preoperative measurements compared to your desired final lengths.

Fig.5

Fig.6

Fig.7

STEP 2: Choose the new maxillary central incisor length
The patient pictured has a maxillary central incisor that measures approximately 7 mm in length. The range of the average maxillary central incisor, unworn and unrestored, is approximately 10–12 mm.^{5, 6} By adding flowable composite to the incisal edge of the central and canine, we can position the central incisor and measure the new desired length of 10 mm (Fig. 8).

If crown lengthening is required, we add the planned reduction in tissue to this measurement to create the overall new maxillary central incisor length.

Fig. 8

STEP 3: Choose the new mandibular central incisor length
The patient’s existing mandibular central incisor length in these examples is also a measurement of 7 mm. The average length of the unworn, unrestored mandibular central incisor is approximately 8 mm.⁷ For this patient we would want to make sure that adding this 1 mm length to the mandibular central incisor position would not create mandibular teeth with too much display. Adding flowable to the length of the mandibular central incisor chairside for evaluation would aid in this determination.

Understanding anterior guidance and the rationale to overbite selection
According to The Glossary of Prosthodontic Terms, anterior guidance is defined as “the fabrication of a relationship of the anterior teeth preventing posterior tooth contact in all eccentric mandibular movements.” Interferences are defined as “any tooth contact that interferes with or hinders harmonious mandibular movement; an undesirable tooth contact.” If a patient has occlusal interferences into closure, meaning that the teeth are not contacting simultaneously into closure, then these contacts are also interferences leaving closure. To further explain this—anterior guidance is immediate disclusion of the posterior teeth in all excursions. If interferences into closure are present, these teeth will prevent the patient from having anterior guidance. There will be simultaneous anterior and posterior contacts present in excursive movements. When back teeth touch, the elevator muscles contraction force increases. If the anterior teeth only are in contact, then the elevator muscle contraction rate decreases.⁸ Developing anterior guidance has also been termed a “mutually protected occlusion.” This means that the anterior and posterior protect one another in function, with the disclusion in all eccentric movements on the anterior teeth only to protect/prevent load increases on posterior teeth in these movements. Lateral contacts on posterior teeth can be particularly damaging during parafunction.^{9, 10, 11, 12}
D’Amico was the first to publish canine guidance as a rationale for parafunctional protection in 1958.¹³ Stuart later further classified the benefit to anterior guidance in eccentric movements¹⁴ as a method to control/mitigate parafunction. Anterior guidance is a night guard or a protective method that the patient cannot take out of their mouth. It is built-in protection. This is particularly important in reconstruction on a patient because studies and publications have shown that there is poor compliance in patients wearing nighttime appliances (10).¹⁵ Because of these factors, we want our final rehabilitation design to have an anterior guidance occlusal scheme.^{16, 17, 18, 19}
Overbite plays a role in anterior guidance in that the steeper the bite, the longer the anterior teeth remain in contact during parafunction. Likewise, the greater the possibility of causing premature contacts on the anterior teeth during function. These premature contacts in the anterior zone during function are called interferences to the envelope of function. It is thus wise to reduce the overbite to prevent these issues from occurring. (For more information on occlusion, please visit dentaltown.com and CE course “Understanding Occlusion.”)

STEP 4: Choose the new CEJ-CEJ measurement (new overbite)
In the previous steps, we have established that we are going to lengthen this patient’s maxillary central to 10 mm. The new chosen mandibular central incisor length is 8 mm. We can now determine how much overbite we want in the new designed occlusion. Although we would not recommend a 0 mm overbite, the purpose of this example is to understand the applied measurements. If we provided a 0 mm overbite, the patient’s new CEJ-CEJ position would have to be 18 mm. The patient’s preoperative overbite was measured to be 3 mm. If we applied this overbite to the patient’s new designed VDO, the final CEJ-CEJ measurement would be 15 mm (Fig. 9).

The patient’s preoperative CEJ-CEJ measurement was 11 mm. Since the final desired vertical dimension is a CEJ-CEJ measurement of 15 mm, we need to increase the VDO by 4 mm to achieve the desired final restorative lengths of the teeth.

Fig. 9

STEP 5: Taking the bite
To review, when designing a new occlusion, we want the final end result to provide anterior guidance. In order to establish anterior guidance, we must have an interference-free occlusion going into closure. The bite record we want to take to provide this occlusal scheme is a centric relation bite record. The traditional centric relation bite recording is taken with the teeth just out of occlusion.²⁰ However, when restoring at an increased vertical dimension we want to provide the lab the exact vertical dimension they are going to build the case to, to prevent any articulation issues.²¹ If we do not provide the exact vertical increase to the lab and ask the lab to create the new VDO by arbitrarily opening the articulator, this can lead to a loss of the accuracy in the horizontal jaw relationship.²² What does this mean to the clinician? The wax-up design will not transfer well to the patient’s mouth and excessive time will need to be spent in adjusting the occlusion of the provisionals.

A simple method to perform a centric relation at the desired increased vertical dimension is to utilize a leaf gauge. The leaf gauge is adjusted to the desired amount of increase, measured with a bogey gauge and placed into the patient’s mouth to confirm the new CEJ-CEJ measurements (Fig. 10). Another method is to use composite cured to the lower incisors, which becomes a fixed leaf gauge where the height can be adjusted with a handpiece to the desired position (Fig. 9). With the leaf gauge in position in the anterior segment, we want to record the posterior open space with an extremely hard bite registration material that will not flex. Traditional bite registration materials do not have a Shore hardness scale high enough to prevent distortion/flexure. The bite registration material I recommend using with any situation that you want to record space, as in a CR bite, is Kettenbach Futar D (Fig. 11). Once the posterior segment is set, the leaf gauge is removed, and the anterior space is then recorded as a separate segment, once again with Futar D (Fig. 12). This same process can be used with a digital scanner to provide the lab with the increased desired vertical dimension for digital design. The lab can now predictably wax up the desired planned aesthetic vertical dimension increase, either traditionally or digitally.

Fig. 10: 10+8-3=15 (3mm overbite)

Fig.11

Fig.12

Once the wax up is completed (Fig. 13), the patient can be placed in provisionals (Figs. 14–16) to test out the aesthetics, function and eccentric/disclusion (left lateral, right lateral and protrusive) movements. This is a more reliable method of testing vertical dimension as opposed to the use of removable appliances.^{23, 24} There are several issues with using removable appliances to try out the new vertical dimension: this does not allow for testing aesthetics, function and speech. Also, while patients can typically tolerate large increases in vertical dimension with removable appliances, have their muscles of mastication remain asymptomatic, and have little to no effect on the temporo-mandibular joint.²⁵ Large increases in vertical dimension would not be tolerated functionally or aesthetically, though, because the patient’s teeth could become too long to satisfy the VDO changes chosen. Over-lengthening teeth would result in issues with speech, aesthetics, mastication and disclusion. For this reason, it is important to start the vertical dimension process with the result in mind.

Fig. 13

Fig. 14: Pre-operative

Fig.15: Provisionals

Fig.16: Protrusive

Using this step-by-step process will allow one to predictably start the rehabilitation process at an increased vertical dimension. Once proven in provisionals, the final lengths and occlusal design can be transferred to ceramics for a predictable aesthetic and functional rehabilitation (Figs. 17–18).^{26, 27}

Fig. 17

Fig.18

References
1. “The Glossary of Prosthodontic Terms 2023.” Journal of Prosthetic Dentistry, vol. 130, no. 4, 2023, pp. e1-e 3.
2. Morley, Jeff, and Jimmy Eubank. “Macroesthetic Elements of Smile Design.” The Journal of the American Dental Association, vol. 132, no. 1, 2001, pp. 39-45.
3. Ackerman, Marc B., and James L. Ackerman. “Smile Analysis and Design in the Digital Era.” Journal of Clinical Orthodontics, vol. 36, no. 4, 2002, pp. 221-236.
4. Misch, Carl E. “Guidelines for Maxillary Incisal Edge Position—A Pilot Study: The Key Is the Canine.” Journal of Prosthodontics, vol. 17, no. 2, 2008, pp. 130-134.
5. Chiche, J. G., and A. Pinault. Esthetic of Anterior Fixed Prosthodontics. Quintessence, 1994, pp. 13-32.
6. Magne, Pascal, German O. Gallucci, and Urs C. Belser. “Anatomic Crown Width/Length Ratios of Unworn and Worn Maxillary Teeth in White Subjects.” School of Dental Medicine, University of Geneva.
7. Volchansky, A., and P. Cleaton-Jones. “Clinical Crown Height (Length) – A Review of Published Measurements.” Journal of Clinical Periodontology, vol. 28, 2001, pp. 1085-1090.
8. Williamson, E. H., and D. O. Lundquist. “Anterior Guidance: Its Effect on Electromyographic Activity of the Temporal and Masseter Muscles.” Journal of Prosthetic Dentistry, vol. 49, no. 6, 1983, pp. 816-822.
9. Schulte, W. Die Exzentrische Okkasion. Quintessenz Verlags, 1983.
10. Paesani, D. Bruxism Theory and Practice. Quintessence Publishing, 2010.
11. Nishigawa, K., E. Bando, and M. Nakano. “Quantitative Study of Bite Force during Sleep-Associated Bruxism.” Journal of Oral Rehabilitation, vol. 28, no. 5, 2001, pp. 485-491.
12. Okeson, J. P. Tratamiento y Afecciones Temporomandibulares. 5th ed., Elsevier, 2003.
13. D’Amico, A. “The Canine Teeth: Normal Functional Relation of the Natural Teeth in Man.” Journal of the Southern California Dental Association, vol. 26, 1958, pp. 194-208.
14. Stuart, C. E., and H. Stallard. “Diagnosis and Treatment of Occlusal Relations of the Teeth.” In: A Syllabus on Oral Rehabilitation and Occlusion, edited by C. E. Stuart and H. Stallard, University of California, 1959.
15. Carlsson, Gunnar E., Anders Johansson, and Sture Lundqvist. “Occlusal Wear: A Follow-Up Study of 18 Subjects with Extensively Worn Dentitions.” Acta Odontologica Scandinavica, vol. 43, no. 2, 1985, pp. 83-90.
16. Fox, Clifford W., Bernard L. Abrams, and Asterios Doukoudakis. “Principles of Anterior Guidance: Development and Clinical Applications.” Journal of Craniomandibular Practice, vol. 2, no. 1, 1983, pp. 23-30.
17. Kohno, Shoji, and Masanori Nakano. “The Measurement and Development of Anterior Guidance.” The Journal of Prosthetic Dentistry, vol. 57, no. 5, 1987, pp. 620-625.
18. McIntyre, Frederick. “Restoring Esthetics and Anterior Guidance in Worn Anterior Teeth.” The Journal of the American Dental Association, vol. 131, no. 9, 2000, pp. 1279-1283.
19. Schwartz, Harold. “Anterior Guidance and Aesthetics in Prosthodontics.” Dental Clinics of North America, vol. 31, no. 3, 1987, pp. 323-332.
20. Dawson, P. E. Functional Occlusion from TMJ to Smile Design. Mosby/Elsevier, 2006.
21. Rivera-Morales, Warren C., and Norman D. Mohl. “Restoration of the Vertical Dimension of Occlusion in the Severely Worn Dentition.” Dental Clinics of North America, vol. 36, no. 3, 1992, pp. 651-664.
22. Preston, Jack D. “A Reassessment of the Mandibular Transverse Horizontal Axis Theory.” The Journal of Prosthetic Dentistry, vol. 41, no. 6, 1979, pp. 605-613.
23. Crins, Luuk A. M. J., et al. “Randomised Controlled Trial on Testing an Increased Vertical Dimension of Occlusion Prior to Restorative Treatment of Tooth Wear.” Journal of Oral Rehabilitation, vol. 50, no. 4, 2023, pp. 267-275.
24. Fabbri, Giacomo, et al. “Increasing the Vertical Dimension of Occlusion: A Multicenter Retrospective Clinical Comparative Study on 100 Patients with Fixed Tooth-Supported, Mixed, and Implant-Supported Full-Arch Rehabilitations.” International Journal of Periodontics & Restorative Dentistry, vol. 38, no. 3, 2018.
25. Rivera-Morales, Warren C., and Norman D. Mohl. “Relationship of Occlusal Vertical Dimension to the Health of the Masticatory System.” The Journal of Prosthetic Dentistry, vol. 65, no. 4, 1991, pp. 547-553.
26. Fayz, Farhad, and Ahmad Eslami. “Determination of Occlusal Vertical Dimension: A Literature Review.” The Journal of Prosthetic Dentistry, vol. 59, no. 3, 1988, pp. 321-323.
27. Abduo, Jaafar. “Safety of Increasing Vertical Dimension of Occlusion: A Systematic Review.” Quintessence International, vol. 43, no. 5, 2012.

Author Bio

Dr. John Nosti practices in Mays Landing and Somers Point, New Jersey, with an emphasis on functional cosmetics, full-mouth rehabilitations and TMJ dysfunction. Nosti is a member of Dentaltown’s editorial advisory board and the clinical director of the Clinical Mastery Series, geared toward advancing knowledge in occlusion, aesthetics and restorative dentistry.

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