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The face is more honest than the mouth will ever be.
Vertical relation of the upper and lower jaws indirectly reflect the changes on the face of a patient. For the edentulous, it is we who have to try and restore it to as normal as possible.
Contents
Introduction Clinical significance of jaw relations in general Definitions Classification History Constancy of facial height concept Methods of recording vertical jaw relation
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Contents (contd.)
Mechanical methods :
Ridge relation Measurement of former dentures Pre-extraction guides :
Profile radiographs Profile photographs Profile tracing (lead wire adaptation) Profile silhouettes Articulated models Dakometer Willis gauge Facial measurement (Tattoo Point) Swensons method Use of anterior teeth
Contents (contd.)
Physiologic methods :
Physiologic rest position Phonetics Facial expression Swallowing threshold Tactile sense
Effects of increased vertical dimension Effects of decreased vertical dimension Conclusion References
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Introduction
VD- Amount of separation of the jaws. Essential in the successful practice of many phases of dentistry. Greatest cause of complete denture difficulties- failure to restore the lost vertical dimension to normal.
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Definition
Maxillomandibular relationship, GPT VIII Any spatial relationship of the maxillae to the mandible; Any one of the infinite relationships of the mandible to the maxillae
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Definition
Vertical dimension, GPT VIII The distance between two selected anatomic or marked points (usually one on the tip of the nose and the other upon the chin), one on a fixed and one on a movable member
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Principle
The single most important factor in deciding the vertical dimension in infants and in edentulous adults is the mandibular musculature.
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Classification
The vertical jaw relation can be classified as follows: 1. Vertical dimension at rest- VDR 2. Vertical dimension of occlusion- VDO
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The repetitive contracted length of the elevator muscles determines the vertical dimension of occlusion.
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Inter-relationship
VDR-VDO=Freeway space or the interocclusal rest space Interocclusal rest space: GPT VIII The difference between the vertical dimension of rest and the vertical dimension while in occlusion.
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Postural rest position is influenced by the position of the lower jaw. A range of posture rather than a single rest position is usually noted.
Postural rest position is further influenced by the position of the head. Upright, unsupported head, while records are made, is the key.
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Swerdlow-1964
Cephalometric study in immediate denture patients over a period of 6 months. The transition period of dentition showed I. Phonetic method was more reliable than the swallowing method. II. VDR and VDO increased initially and then decreased markedly in 6 months. III. The interocclusal distance is self adjusting. IV. Mandibular load influenced the rest position.
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Neuromuscular disturbances make the records difficult. With these patients the operator must be very considerate and cool.
Syllabus of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn, 4th Edition
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Factors(contd.)
The dentist should be prepared to make measurements without delay when the position is assumed because the rest position is not to be maintained for a duration of time. No one method for determining rest position can be accepted as being valid for all patients. Several methods are available to confirm this record.
Syllabus of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn, 4th Edition.
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Ridge relations
Parallelism of ridges: Paralleling and a 5 degree opening in the posteriors as acceptable was suggested by Sears. Marked resorption of the ridges makes this rule void. Distance of incisive papilla from mandibular incisors: A stable landmark, little change on resorption. Gives an average measure of the vertical overlap.
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Pre-extraction guides
One can usually establish an occlusal position, record it and transfer it to the edentulous situation.
There are several ways of accomplishing it.
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Profile radiographs
Lateral skull radiographs before and after extractions with trial bases.
Comparisons help to bring the necessary changes in the position of the mandible
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Profile photographs
Made with teeth in maximum occlusion. Measure of the anatomical landmarks on the photographs are compared. When the records are made and when the try in is done. Disadvantages : Angulation of the photos might differ. Photo enlargements cause inaccuracies.
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Dakometer
Bennett's Dakometer made by Elliot brothers in London during 1929-35. Records both the vertical dimension with natural teeth and the position of the central incisors. Consists of the nose and chin piece which are secured with compound to measure the readings on the spring gauge (on the right).
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The distance from the lower border of the septum of the nose to lower border of the chin is equal to distance from the outer canthus of the eye to the corner of the mouth in the rest position.
Disadvantage being inaccuracy, as the degree of pressure applied may not be 42 same every time.
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This could possibly be the most phased out technique for obvious reasons of permanent tattoos.
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Fayz F, Eslami A, Craser G ; Use of anterior teeth measurement in determining occlusal vertical dimension, J Prosthet Dent, 1987, 58 (3) : 317 322
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Niswongers method
The campers plane or the ala-tragus line and the inter- pupilliary line are the hallmarks of this procedure. An upright position leads the planes to be parallel to the floor. The marks are made on the tip of the nose and the most stable area on the chin.
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The distance between the marks is recorded after the patient is asked to swallow and relax. Subsequently occlusal rims are fabricated so that when they occlude, have a measurement 1/8 less than the original measurement. This 1/8 average gives a freeway space of 2 to 4 mm.
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Boucher LJ, Zwemer TJ and Pflughoeft F, Can biting force be used as a criterion for registering vertical dimension?, J Prosthet Dent, Volume 9, 4, JulAug 1959, Pages 594599 52
Lytle RB, Vertical relation of occlusion by the patient's neuromuscular perception, Volume 14, Issue 1, JanuaryFebruary 1964, Pages 1221
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Electromyography
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From Michelloti A, Faralle M, Vollaro S et al.: Mandibular rest position and electrical activity of the masticatory muscles, J Prosthet Dent 78: 48-53, 1997. 55
Electromyography
Neuromuscular dentistry has found an important position in Prosthodontics. The rest position of the mandible can be determined by means EMG activity. Hence a stable reference point may be achieved for recording vertical dimension values. Disadvantages:
Physiologic methods
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Method
The method was originally evaluated in natural dentition by Silvermann. The reference lines were marked on the lower anterior tooth. With respect to the artificial dentition, keeping the labio-lingual thickness of the occlusal rims as that of the natural or denture teeth is important.
Silvermann MM, The speaking method in measuring vertical dimension, J Prosthet Dent, 3, 2, March 1953, Pages 193199
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Facial expression
Vertical relation at rest can be judged by a number of facial details. In normal related jaws, the lips will be even antero-posteriorly and in slight contact. Patient with a retruded mandible has uneven lip position and the two are not in contact. Vice versa is observed in case of prognathic mandibles. Skin around eyes and chin should be relaxed, relaxation around the nares reflects unobstructed breathing.
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Swallowing threshold
At the beginning on the swallowing cycle the teeth come together with a very light contact. The technique involves building cones of soft wax on the lower denture base so that it contacts the upper occlusal rims with the jaws too wide open. The flow of saliva stimulated and the repeated action of swallowing will gradually reduce the height of wax cones to allow the mandible to reach the level of occlusal vertical relation. Cine-fluorographic studies on swallowing patterns affecting the vertical dimension is shown by Sheppard and Sheppard.
Sheppard I, Sheppard S; The relationship of vertical dimension to atypical swallowing with complete dentures, JPD, Vol38, 3, Sept. 1977, Pages 249253
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Tactile sense
This method is almost identical to the neuromuscular perception method described earlier. A central bearing device may or may not be used for determining the correct vertical. The patients neuromuscular coordination is important, it might not be useful for senile patients or the ones with impaired neuromuscular coordination.
Boucher mentions it as Patient perceived comfort
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Appearance : Elongated appearance and at rest the lips are parted; Patient tries to close them together producing an expression of strain. Bone resorption : Due to continuous pressure on the residual alveolar ridge it undergoes rapid resorption.
Loss of retention and stability : Leverages are caused due to premature contacts, further loss of ridge leads to loss of retention and stability. Generalized Hyperemia : Space between the teeth is essential when mandible is at rest. If no space is present between the teeth in denture, it may result in generalized hyperemia.
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Mc Cord, Grant; Prosthetics: Registration Stage II: Intermaxillary relations, British Dental Journal 188, 601 - 606 (2000)
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A METHOD FOR CORRECTION OF INCREASED VERTICAL DIMENSION IN COMPLETE DENTURES, Kharat DU. 69
Cheek, Tongue and lip biting : Loss of muscular tone, as well as reduced vertical height, the flabby cheek tend to become trapped between the teeth during mastication.
Appearance (Denture look) : The general effect of over closure on facial appearance is of increased age because of closure approximation of nose to chin, soft tissue sag and fall in and the lines on the face are deepened. Inadequate lip support results in a flat upper lip with loss of vermillion border, loss of muscular function and loss of dominance of upper lip over lower lip will give a denture look. 70
Angular cheilitis (perleche) : A reduced vertical dimension results in a crease at the corners of the mouth beyond the vermilion border and the deep fold thus formed becomes bathed in saliva thus leading to infection and soreness.
Pain in temporomandibular joint : Over closure may cause pain in temporomandibular joint probably due to strain of the joint and associated ligaments.
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Costens syndrome (Mild catarrhal deafness): There will be a tendency to push the tongue towards the throat, adjacent tissues will be displaced, which may in turn result in occlusion of Eustachian tubes which would interfere with function of ear which may cause ear discomfort and impaired hearing. Tinnitus or snapping noises in joint. Tenderness to palpation over T.M.J. Dryness of the mouth. Various neurologic symptoms such as burning or picking sensation of the tongue. Prognathism : Over the years as a result of resorption of ridges and abrasion of denture teeth, there is a loss of occlusal vertical dimension. So the lower jaw over-closes in a forward and upward direction. Then the patient may appear prognathic.
Weinberg L, Role of condylar position in TMJ dysfunction-pain syndrome, J Prosthet Dent, Vol 41, 6, Jun 1979, Pages 636643
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Mc Cord, Grant; Prosthetics: Registration Stage II: Intermaxillary relations, British Dental Journal 188, 601 - 606 (2000)
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Conclusion
Many methods of assessing and recording vertical jaw relations in edentulous patients have been presented and evaluated. Since there is no precise scientific method of determining the correct vertical relations, the registration of vertical relations depends upon the clinical experience and judgment of the dental surgeon himself.
It is art rather than a science. This is the reason why there are several of methods in use and why one method is as good as other.
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References
Prosthodontic treatment for edentulous patients : Boucher Syllabus of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn Complete denture prosthodontics : John .J Sharry Functional Occlusion, From TMJ to smile design: Peter E Dawson Irving M. Sheppard, Stephen M. Sheppard, Vertical dimension measurements, JPD 1975, 34(3) : 269 277 A.J. Turell; Clinical assessment of vertical dimension, JPD 1972, 28(3) : 238 246 Silvermann MM; The speaking method in measuring vertical dimension, JPD 1953, 3(2) : 193 199 Swerdlow H; Vertical Dimension literature review, J Prosthet Dent March April 1965, Vol 15, no. 2. 241-247.
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References
Farhad Fayz, Ahmad Erlami, Gerald N. Grascr ; Use of anterior teeth measurement in determining occlusal vertical dimension, JPD 1987, 58 (3) : 317 322 Wein L.A. Vertical dimension A research and clinical analysis, JPD 1982, 47 (3) : 290 302 Kleinman .A.M. Shephard J.M, A direct procedure for indicating mandibular rest portion JPD 1972 ; 28 : 19 20 Wagnu A. G Comparison of 4 methods to determine rest portion of the mandible, JPD 1971, 25 : 506 514 Lytle RB, Vertical relation of occlusion by the patients neuromuscular perception, JPD 1964, 14 : 12 21 Mc Cord, Grant; Prosthetics: Registration Stage II: Intermaxillary relations, British Dental Journal 188, 601 - 606 (2000). Glossary of prosthodontic terms : VIII Edition
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