Diagnosis of the Vertical Dimension

James L. Vaden and Lloyd E. Pearson

The vertical dimension problem is complex and multifactorial, Not only
must the clinician recognize a vertical discrepancy abnormality, he/she must
be able to recognize its numerous components and understand their interrelationships, Many scientific investigators and orthodontic clinicians have
contributed to the body of knowledge to which we have access. This article
reviews some of the pertinent literature and offers some diagnostic and
treatment planning suggestions to the clinical specialist who struggles with
the vertical dimension enigma on a daily basis, (Semin Orthod 2002;8:
120-129,) Copyright 2002, Elsevier Science (USA). All rights reserved.

he h u m a n face has been the subject of

study since man could first express himself.
As civilizations have risen and subsequently
faded away, one thing that has remained is art,
in most cases, drawings, paintings, and so on of
faces. During the Renaissance, da Vinci, Michaelangelo, and D u h r e r led o t h e r artists to study
faces. Facial p r o p o r t i o n was discovered; there
were standards set for balance and h a r m o n y of
the lower face. In our specialty of orthodontics,
Angle was vitally c o n c e r n e d about the face. In
his sixth edition, 1 he states, "One of the evil
effects of malocclusion is the marring or distorting of the normal facial lines. It follows that, in
the application of the principles of orthodontia,
our efforts should be so directed as to mold and
modify these lines of i n h a r m o n y to those of
h a r m o n y and facial beauty so far as lies within
the range of the possibilities of art, and of the
type and t e m p e r a m e n t of the individual. O u r
opportunities for benefiting humanity are very
great in this field, far exceeding those offered by
any other branch of dental science, for patients
with facial lines so distorted as sometimes to be
a marked deformity and a source of constant
humiliation to themselves and their friends may

Prom the Department of Orthodontics, University of Tennessee,

Memphis, TN; and a Private Practice, Edina, MN.
Address cor~rspondence to James L. Vaden, DDS, M8, Department of Orthodonti~, University of Tennessee, Health Seienee Center, 875 Union Avenue, Memphis, TN 38163.
Copyright 2002, Els~ier Science (USA). All rights trserved.
1073-8746/02/0803-0003535.00/0
doi:l O.1053/sodo. 2002.125431

120

now be so treated as to bring about a complete

transformation of the facial expression, even to
the establishment of lines of beauty."
Tweed revolutionized orthodontic diagnosis
because of his c o n c e r n for the balance and harm o n y of the lower face. Many in our specialty
have studied the face, z-6 developed diagnostic
guidelines for quantifying facial balance, 7-u and
proposed treatment regimens that give the orthodontic clinician a greater certainty that facial
balance and h a r m o n y is an attainable goal for
their patients.
The underlying theme that surfaces from all
artists and orthodontic investigators is the concept that there c a n n o t be good balance and
h a r m o n y in the lower face unless the vertical
dimension is within normal limits. The most
important prerequisite for facial balance is a
normal vertical dimension of the lower face.
Poulton 12 c o n d u c t e d a study on cervical traction
and f o u n d that large lower anterior facial
heights were most often associated with a displeasing face. In their article on soft-tissue profile preference, DeSmit and DermauO 3 created
three different series of nine profile photographs so that a total of more than 200 profiles
could be ranked by graduate dental students.
They f o u n d that differences in gender and orthodontic knowledge of the students seemed to
have no significant influence on their esthetic
preference. The results of their study confirmed
the importance of anteroposterior deviations
but suggested that unaesthetic facial profiles
that were a result of anteroposterior deviations
were completely overshadowed by long-face fea-

Seminars in Orthodontics, Vol 8, No 3 (September), 2002: pp 120-129

Diagnosis of the Vertical Dimension

t u r e s - - t h e long-face feature being m o r e unaesthetic. Because of the challenge of the vertical

dimension, the subject of this article is of extreme i m p o r t a n c e to the orthodontic specialist.
Not only must the specialist recognize the problem, the specialist must u n d e r s t a n d the diagnosis of the p r o b l e m so that all facets and components of the vertical dimension e n i g m a are
understood. T h e clinician must be able to recognize the various c o m p o n e n t s of a vertical dimension abnormality and u n d e r s t a n d the interrelationship of all the elements of the problem.
Before discussing the abnormal, it is p r u d e n t
to understand the normal. Two of the most accepted descriptions or publications of vertical
facial proportions have b e e n published by Frakas 14 and Frakas and Munro. 15 In these, they
describe the ideal face as vertically divided into
equal thirds by horizontal lines that approximate the hairline, the bridge of the nose, the ala
of the nose, and m e n t o n (Fig 1)J 6 Figure 1 also
shows that in the ideal vertically p r o p o r t i o n e d
face there is a further division of the lower one

1/3

113

113

Figure 1. The ideal facial proportions as described

by Frakas 14 and Frakas and Munro. 15 The frontal
view of the face is divided into equal thirds by
horizontal lines that approximate the hairline, the
bridge of the nose, and the ala of the nose and
menton. The lower third is further divided into an
upper third and a lower two third.

121

third of the face into an u p p e r one third and a

lower two third. These divisions of the face can
be used by the clinician to help diagnose vertical
dimension problems. For example, does a patient have a disproportionately long lower facial
height because of vertical maxillary excess or to
excessive chin height? Conversely, is a short facial height caused by vertical maxillary deficiency or a short chin height? 17 By using these
accepted proportions as a guide, the patient
shown in Figure 2 has an excessive lower anterior facial height, whereas the patient shown in
Figure 3 has diminished lower anterior facial
height. Although it is evident that both have
vertical dimension abnormalities by looking at
the face, measuring the facial proportions confirms this intuitive conclusion. A careful determination of the vertical proportions of the face
is therefore the first step in the diagnosis of a
vertical dimension problem.
Role of Skeletal and Dental
Relationships
After examining the face and quantifying its proportions, the skeletal pattern and the teeth and
their relationships to each other must be scrutinized. However, a diagnosis of the vertical dim e n s i o n is m o r e complicated because vertical
discrepancy malocclusions are nmltidimensional. For example, dentoalveolar abnormalities can impact the skeletal pattern, and p o o r
skeletal patterns can cause dentoalveolar compensations that are difficult for the clinician to
correct. T h e following variations can be present,
either alone or in combination: (1) maxilla:
maxillary posterior alveolar excess and inferiorly
positioned maxilla and (2) mandible: mandibular posterior alveolar excess and short mandibular rami. O t h e r abnormalities may include
superiorly positioned condylar fossa, obtuse cranial base angle, and condylar resorption.
Any of these conditions, with or without aberrant m a n d i b u l a r growth rotation, can be a
causative factor in the vertical discrepancy malocclusion.
Condylar

Growth

A c o m m o n scenario affecting the skeletal problem is m a n d i b u l a r growth a n d growth rotation,

which unfavorably impacts dentoalveolar devel-

122

Vaden and Pearson

Figure 2. An example of a
patient with an excessive
lower facial height.
o p m e n t in both the maxilla and mandible.
Bjork is-21 and Bjork and Skieller 2:~,24 have perf o r m e d n m n e r o u s studies that have shown that
the most c o m m o n direction of condylar growth
is vertical, with some anterior c o m p o n e n t . Patients with a p r o n o u n c e d short lower anterior
facial height (Fig 4A and B) generally exhibit
upward and forward condylar growth (Fig 5).
These individuals generally have a d e e p vertical
overbite with a d e e p mentolabial sulcus and a
strong overclosed appearance. 25 In contrast, pa-

Figure 3. An example of a
patient with a diminished
lower facial height.

tients with long-face syndrome (Fig 6A and B)

have a m o r e posteriorly directed growth pattern
of the m a n d i b u l a r condyle (Fig 7). 26,27 These
backward growth rotators have increased anterior facial height, a m o r e posterior position of
the chin, and in e x t r e m e cases, an anterior o p e n
bite may develop. Serial images of the patient
taken to m o n i t o r the direction of condylar
growth would be very useful for the diagnosis of
vertical growth. At the present time, serial imaging poses certain concerns, most significantly

Diagaosis of the Vertical Dimension

123

Figure 4. A patient with a pronounced short lower anterior facial height. (A) The cephalometric radiograph is also shown. (B)

radiation exposure. Advances in imaging technology may, in the future, p e r m i t the clinician to
use these m e t h o d s for diagnostic purposes with
greater safety.
An understanding of the maxillomandibular
growth rotation of the patient would be most
helpful in the diagnosis of vertical variations.
Bjork u8 has contributed information that offers
some guidelines for the clinician to assist in the
determination of the growth rotation of the
mandible so that the c o n c o m i t a n t vertical
changes are m o r e easily understood. Bjork's

m e t h o d of prediction of condylar growth rotation from a c e p h a l o g r a m offers the clinician

some guidelines. Bjork identified seven specific
structural features that m i g h t develop as a result
of r e m o d e l i n g during a particular type of growth
rotation. Bjork's suggestions for predicting condylar rotation have, however, not b e e n widely
used by the specialty because (1) some of the
indicators cannot be easily seen on the average
cephalogram, (2) the use of the indicators is vmT
time-consuming for the clinician, and (3) there
has b e e n no scientific validation of the suggested

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Vaden and Pearson

the backward rotator exhibits (1) a straight inclination of the condyle, (2) a relatively straight
mandibular canal, (3) the symphysis slopes forward and, (4) lower anterior facial height is
long.
Isaacson, 29 Isaacson et al, 3 and Schudy, ~ following on Bjork's reports, studied jaw rotation
caused by vertical condylar growth. A succinct
summary of the findings of these investigators is
that a forward mandibular rotation occurs when
vertical condylar growth exceeds the sum of the
vertical growth of the maxillary sutures and the
maxillary and mandibular alveolar processes. If
growth of the maxillary sutures and the maxillary/mandibular alveolar processes exceeds vertical condylar growth, a backward rotation
occurs, and the face becomes longer. An understanding of the effect of condylar growth on
mandibular position is fundamental if the clinician is to adequately and appropriately diagnose
a vertical dimension abnormality.

Figure 5. An example showing upward and forward

condylar growth.
indicators because of difficulties e n c o u n t e r e d in
study design. Some in the specialty also question
whether several of the suggestions are valid indicators of a particular type of growth rotation.
However, when used for their intended purpose,
as guidelines only, the indicators have some useful clinical applications in the diagnosis of the
patient with vertical dysplasia (Table 1).
Using Bjork's guidelines, it is interesting to
study Figures 4B and 6B. Figure 4B, the forward
rotator, exhibits several of Bjork's indicators including observations that (1) the condylar head
curves forward, (2) the mandular canal is
curved, (3) the symphysis has a backward cant,
(4) the interincisal angle is obtuse and, (5)
lower anterior facial height is short. Figure 6B,

Anterior and Posterior Facial Height

Vertical dimension skeletal abnormalities are
not solely caused by condylar growth direction.
They are also caused by differences in anterior
facial height and posterior facial height development. These differences in height development
can lead to rotational growth or to changes in
mandibular position that greatly influence the
position of the chin. ~ Etiologies influencing unfavorable differences in development of anterior
and posterior facial height are nmltifactorial.
These factors can, for simplicity, be subdivided
into those caused by (1) dentoalveolar developm e n t and (2) environmental factors.

Dentoalveolar Development
Issacson et al 3~ studied dentoalveolar developm e n t in three groups of subjects--those with

Table 1. Bjork's Seven Structural Guidelines 2s

Inclination of the condylar head

Curvature of the m a n d i b u l a r canal
Shape of the m a n d i b u l a r lower border
Inclination o f the symphysis (Anterior aspect j u s t below "B" point)
Interincisal angle
l n t e r p r e m o l a r or intermolar angles
Anterior lower face h e i g h t

Fo~t~ard Pvotator

Backward Rotator

Cupees forward a n d back

Curved
Curved downward
Slopes backward
Vertical or obtuse
Vertical or obtuse
Short

Straigbt or slopes u p
Straight
Notchcd
Slopes fi)iveard
Acute
Acute
Tall

Diagnosis of the Vertical Dimension

125

Figure 6. An example of a patient with long-face syndrome.

short anterior facial height, those with average
anterior facial height, and those with excessive
anterior facial height. T h e a m o u n t of maxillary
posterior alveolar d e v e l o p m e n t was t o u n d to decrease as the MP-SN angle decreased. In patients
with long anterior facial height (high MP-SN
angles), the m e a n distance f r o m the occlusal
plane to the inferior edge of the palate was 22.50
m m . This distance decreased to 19.6 m m for the
average g r o u p and 17.1 m m for the g r o u p with

short anterior facial height (low MP-SN angles).

This difference of 5.1 m m of dentoalveolar dev e l o p m e n t between the high angle and low angle groups is of significance.
M a n d i b u l a r p o s t e r i o r alveolar d e v e l o p m e n t
similarly d e c r e a s e d with decreases in the
MP-SN angle b u t m u c h less dramatically t h a n
those f o u n d in the maxilla. M a n d i b u l a r h e i g h t
showed a m e a n of 31.2 m m for the l o n g anterior face h e i g h t g r o u p , 28.2 for the average

126

Vaden and Pearson

Figure 7. An example showing a posterior-directed

growth pattern of the mandibular condyle.

group, a n d 28.3 for the s h o r t a n t e r i o r face

h e i g h t group.
The findings of the Issacson et a133 study were
confirmed in a study p e r f o r m e d by J a n s o n et
al. 34 These investigators f o u n d that all dentoalveolar heights were significantly greater in long
anterior facial height patients than in patients
with n o r m a l facial height. Also, in the short
lower anterior facial height, all dentoalveolar
heights were significantly shorter than in the
n o r m a l lower anterior facial height group.
T h e differences in dentoalveolar development, most particularly in the maxilla, have a
significant impact on the anterior facial height
of the orthodontic patient. Moller and Ingerval135 and T h i l a n d e r :~6 have postulated that excessive maxillary posterior dentoalveolar develo p m e n t is associated with weaker masticatory
musculature in high-angle patients c o m p a r e d
with the strong musculature c o m m o n l y associated with short anterior facial height patients.

Enviornmental Role--Swallowing and

Tongue Posture
T h e role of tongue posture, swallowing, and
breathing are still subjects of debate, argument,
and study in orthodontics. Their respective impact on the vertical dimension are in n e e d of
continued study and research.

Mouth breathing. T h e relationship between

m o u t h breathing, altered posture, and the dev e l o p m e n t of malocclusion is not as clear cut as
the theoretical o u t c o m e of shifting to oral respiration m i g h t a p p e a r at first g l a n c e Y Recent experimental studies have only partially clarified
the situation. C u r r e n t e x p e r i m e n t a l data for the
relationship between malocclusion and m o u t h
breathing are derived f r o m studies of the nasal/
oral ratio in normal versus long-face c h i l d r e n Y
T h e data from the study show that both normal
and long-face children are likely to be predominantly nasal breathers u n d e r laboratory conditions. A minority of the long-face children had
less than 40% nasal breathing, whereas n o n e of
the normal children had such low nasal percentages. W h e n adult long-face patients are examined, the findings are similar: the n u m b e r with
evidence of nasal obstruction is increased in
comparison to a n o r m a l population, but the
majority are not m o u t h breathers in the sense of
p r e d o m i n a n t l y oral respiration.
Airway problems, such as large adenoids, tonsils, or blocked ail~vays caused by septum deviations, large conchae, or allergies are frequently
observed in high-angle patients and may affect
m a n d i b u l a r posture, allowing m o r e f r e e d o m for
posterior eruption. This hypothesis is s u p p o r t e d
by Linder-Aronson 39,4 who showed closing of
the m a n d i b u l a r plane angle and reduction in
the anterior face height after removal of adenoids and tonsillectomy.
It appears that research on respiration, up to
the present time, has resulted in two opposing
views: (1) total nasal obstruction is highly likely
to alter the pattern of growth and lead to malocclusion in e x p e r i m e n t a l animals and humans,
and individuals with a high p e r c e n t a g e of oral
respiration are overrepresented in the long-face
population, but (2) the majority of individuals
with the long-lace pattern of deformity have no
evidence of nasal obstruction and must therefore have some o t h e r etiologic factor as the principal cause.
In conclusion, it appears that m o u t h breathing may contribute to the d e v e l o p m e n t of orthodontic p r o b l e m s but is difficult to indict as a
frequent etiologic agent. Clinically, most orthodontists refer m o u t h breathers to an otolaryngologist tbr an evaluation. This p r o b l e m should
be carefully evaluated during the diagnosis of a
patient with excess vertical dimension.

Diagnosis of the VerticalDimension

Swallowing and tongueposture. O n e viewpoint

holds that t o n g u e thrust swallowing is seen in
(1) y o u n g e r children with r e a s o n a b l y n o r m a l
occlusion in w h o m it r e p r e s e n t s only a transitional stage in n o r m a l physiologic m a t u r a t i o n
a n d (2) in individuals who have displaced incisors. In the latter, it is an a d a p t a t i o n to
the space b e t w e e n the teeth. O t h e r s a r g u e that
t o n g u e thrust swallowing simply has too
s h o r t a d u r a t i o n to have an i m p a c t o n t o o t h
position. Pressure by the t o n g u e against the
teeth d u r i n g a typical swallow lasts for a p p r o x imately 1 second. A typical individual swallows a b o u t 800 times p e r day while awake b u t
has only a few swallows p e r h o u r while asleep.
T h e total p e r day, t h e r e f o r e , is usually u n d e r
1,000. O n e t h o u s a n d seconds of pressure, of
course, totals only a few minutes, n o t nearly
e n o u g h time, it is argued, to affect the equilibrium. 41
Most clinicians believe that if a patient has a
forward resting posture of the tongue, the duration of this pressure, even if very light, could
affect tooth position, vertically or horizontally.
Tongue-tip protrusion during swallowing is
sometimes associated with a forward tongue posture.
During the diagnosis of the patient with a
vertical dimension problem, the clinician must
u n d e r s t a n d that condylar growth, sutural lowering of the maxillary complex, dentoalveolar development, dental eruption, and the patient's
oral e n v i r o n m e n t / h a b i t s are interrelated. T h e r e
is not generally a single causative factor that
predisposes the patient to too m u c h or too little
vertical d e v e l o p m e n t of lower facial height. To
simplify, one might conclude as a general rule,
that when vertical condylar growth exceeds
tooth eruption (alveolar development), forward
m a n d i b u l a r rotation occurs. T h e result is increased posterior facial height a n d an increase
in the ratio of posterior facial height to anterior facial height. Conversely, if dentoalveolar
growth and tooth eruption are greater than vertical condylar growth, the resultant m a n d i b u l a r
change is backward rotation. T h e anterior facial
h e i g h t / p o s t e r i o r facial height ratio decreases. 42
Environmental factors can play a role, but the
role is, at times, difficult to assess and varies f r o m
patient to patient.

127

Diagnostic Considerations
Steep Excess Vertical Pattern:
The Backward Rotator
During differential diagnosis of the high-angle
patient, two questions must be asked. First,
where should the teeth be positioned? For the
patient with long anterior facial height, the mandibular anterior teeth are most often positioned
in a m o r e retracted posture over basal bone. Lip
p r o c m n b a n c y can be best resolved if the mandibular anterior teeth are upright. T h e a m o u n t
of uprighting that must be achieved is a matter
of (1) clinical preference and must be determ i n e d during the t r e a t m e n t p l a n n i n g phase of
the t r e a t m e n t protocol or (2) the dictates of the
malocclusion. If indeed the facial profile of the
patient with excess vertical dimension is long, a
vertical reduction genioplasty can be effective
for facial esthetics. It is f u n d a m e n t a l for the
clinician to be able to visualize the posttreatm e n t positions of the m a n d i b u l a r anterior teeth
during t r e a t m e n t plan preparation. Secondly,
will extractions be necessary? For m a n y patients
with excessive lower anterior facial height, extractions may be necessary. T h e question of
which teeth should be extracted can be answered only after a t h o r o u g h and accurate differential diagnosis.

The Overdosed Forward Rotator

Patients with short anterior vertical facial height
have a unique set of problems that require different diagnostic considerations. The following
diagnostic guidelines should be considered
when a patient with this skeletal pattern is
treated without surgical intervention.
Mandibular incisors, if well aligned before
treatment, can be allowed to remain in their
p r e t r e a t m e n t position. Uprighting of mandibular incisors has an adverse impact on facial esthetics of the low-angle patient. However, the
m a n d i b u l a r incisors, if malaligned, should not
be proclined beyond their bony support for the
p u r p o s e of alignment.
Some overclosed forward rotator malocclusions are characterized by a d e e p vertical overbite, maxillary incisor protrusion, a n d / o r crowding. Correction of the overbite for these patients
is best accomplished by intrusion and retraction
of the maxillary incisors.

128

Vaden and Pearson

Treatment Concerns
During the diagnosis of the vertical dimension
problem, the clinician must be attentive to the
force systems that are p l a n n e d for treatment and
understand that undesirable reactions to incorrectly applied fbrce systems are disastrous. Posterior facial height must be carefully controlled
for the high-angle patient because an increase in
posterior facial height will result in an increase
in anterior facial height. 434~ An increase in anterior facial height of high-angle patients is calamitous.
An important mechanical tooth manipulation
that must be accomplished during the treatment
of the patient with excess vertical dimension is
prevention of extrusion of the mandibular posterior teeth, assuming that the maxillary posterior vertical dimension is controlled by intrusive
forces (ie, headgear or other methods). Extrusion in the molar areas will prevent successful
correction of the malocclusion with excess vertical dimension and long lower anterior t:ace
height. It is important for the clinician to understand these concepts during diagnosis and treatm e n t planning so that extraoral traction can be
planned to help control the vertical dimension
during treatment. There should be intrusive
forces to the posterior segments of both arches.
Additionally, Class II elastic wear can be one of
the most detrimental force applications that is
applied to a patient with long lower anterior
facial height. If Class II elastics are used indiscriminately on the high-angle patient, the mandible drops down and back and increases the
sagittal discrepancy. Therefore, Class II elastic
use, or the absence of it, must be planned for
during diagnosis and treatment planning.
Pearson 4~ has published his results using vertical pull chin cups and has provided evidence
that their use can create some effective skeletal
changes for the long-face patient. A thoughtful
diagnostician nmst consider the use of whatever
means is necessary to impact treatment and prevent the lengthening of lower anterior facial
height during the course of treatment.

Summary
The orthodontic clinician must make a careful
differential diagnosis for each patient who seeks
his or her care. The diagnosis must analyze all

three c o m p o n e n t s of a malocclusion facial,

dental, and skeletal. Each c o m p o n e n t must be
carefully studied and u n d e r s t o o d so that (1) the
p r o p e r questions are asked and (2) the correct
diagnostic decisions are made to lead to an effective treatment plan.
Diagnosis of the vertical dimension is a con>
plex problem. Yet, it can be as simple as studying
a face and applying c o m m o n sense diagnostic
tools to ascertain the reason that the lower face
is too long or too short. The vertical dimension
has been a subject of study and debate since
orthodontics became a specialty. Researchers in
the field of vertical dimension diagnosis, including Bjork, is Schudy, 27 Nielsen, 25 Isaacson, 29
Pearson, ~6 and others, have provided the specialty many useful guidelines and concepts that
can be used by every orthodontic clinician as
they diagnose a malocclusion that is complicated
by a vertical dimension discrepancy. Orthodontists should continue to use the work of these
researchers and clinicians for a foundation as
more studies are u n d e r t a k e n that will yield more
knowledge so that diagnosis of the vertical dimension becomes less art and more science.

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Diagnosis of the Vertical Dimension

14. Frakas LG: AnthropomeUT of the Head and Face in

Medicine. New York, NY, Elsevier Science, 1981
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