VERTICAL JAW RELATION

Presented By: Dr. Kelly Norton

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 INTRODUCTION
• Recording of jaw relations in the treatment of edentulous patients
aims at facilitating the adaptation of the complete denture to the
masticatory system to give them an optimal and comfortable
function.
• To achieve this goal, the recording must include an approximate
vertical dimension of occlusion, stable occlusal contacts in harmony
with the existing TMJ and masticatory muscle functions.
.
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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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 Classification of Jaw relations

• Orientation jaw relation.

• Vertical jaw relation.

• Horizontal jaw relation.

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 Classification

• The vertical jaw relation can be classified as follows:

1) Vertical dimension at rest- VDR
2) Vertical relation at occlusion-VDO

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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 is:
the mandibular musculature and occlusal stops or occlusion rims
from the teeth.

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HISTORY
PROPONENT THEORY
HUNTER(1771) Lies in the middle of extremes of motion by which all the muscles
and ligaments are equally relaxed.
WALLISCH(1906) All muscle action eliminated
Mandible passively suspended
Opposing teeth no contact
NISWONGER(1934) -1st investigator to study extensively the rest position of mandible
Constancy concept of by recording measurements on patients.
face height -Rest position is a neutral position of the mandible since the
opening and closing muscles are in a state of equilibrium.
-Jaw relator-A gauge to measure the vertical dimension of the face
Thompson and Brodie Thomson believed that the rest position is determined by a
(1942) balance of tension in the musculature which suspends the
mandible and that the rest position is not affected by the
presence or absence of teeth. They stated, “The proportions of
face as far as vertical height is concerned, are constant
65 through out life 8
Leof (1950) -Stressed that muscle tone rather than muscle length
controls the rest position, and that muscle tone can vary.
-Muscle tone can be increased by exercise and decreased by
excessive rest.

Meyer M Presented a physiologic phonetic method of measuring the

Silverman vertical dimensions of the closest speaking space
(1952-1953)

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Toolson LSmith D. Clinical measurement and evaluation of vertical dimension.

The Journal of Prosthetic Dentistry. 2006;95(5):335-339.
Zarb, Bolender – Two hypothesis about rest position
1. Active mechanism
This position is assumed only when the muscles that
close the jaws and that open the jaws are in a
state of minimal contracture to maintain the
posture of the mandible.

2. Passive mechanism
Elastic elements of the musculature, and not any
muscle activity, balance the influence of gravity.

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 Physiologic rest position
GPT-VIII
• 1: The mandibular position assumed when the head is in an
upright position and the involved muscles, particularly the
elevator and depressor groups, are in equilibrium in tonic
contraction, and the condyles are in a neutral, unstrained
position
• 2: The position assumed by the mandible when the attached
muscles are in a state of tonic equilibrium. The position is usually
noted when the head is held upright
• 3: The postural position of the mandible when an individual is
resting comfortably in an upright position and the associated
muscles
65
are in a state of minimal contractual activity 11
 Significance of Physiological Rest
position

• Bone to bone relation

• Fairly constant throughout the life
in absence of any pathosis.
• Can be recorded and measured
within acceptable limits.
• Used to determine the VDO.

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Textbook of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn, 5th Edition
Vertical dimension of occlusion, GPT VIII

Occlusal vertical dimension

The distance measured between two points when the occluding
members are in contact.

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 Vertical Dimension at Rest
• Definition: -
• The distance between two selected points (one of which is on the middle of the face or
nose and the other of which is on the lower face or chin) measured when the mandible is in
the physiologic rest position-GPT-8

• It is essential to record the vertical dimension at rest as it acts as a reference point during
recording the vertical dimension at occlusion.
• The VD at rest should be recorded at the physiological rest position of the mandible.

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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.
It ranges from 2-4 mm in
vertical direction at the
position of the 1st premolar

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 Gravity

Factors
considered
calm, cool and Neuromuscular
relaxed for rest disturbances
position

make
measurements
without delay

No one method for determining rest position can be accepted as being valid for all patients.
Several methods are available to confirm this record
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Syllabus of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn, 4th Edition
 Classification of the methods
• Mechanical : Physiological
1. Physiological Rest Position
• 1. Ridge relation
2. Phonetic and Esthetics as guides
A.Incisive papilla to mandibular incisors 3. Swallowing threshold
4.Tactile Sense
B. Parallelism of the ridges
• 2. Measurement of the former dentures
• 3. Preextraction records
A. Profile radiographs
B. Casts of teeth in occlusion
C. Facial mesurements
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 MECHANICAL METHODS
RIDGE RELATIONS

• 1.Incisive papilla to mandibular incisors

• Incisive papilla – stable landmark
• Distance :
Papilla -Incisal edges of mandibular anterior teeth : 4 mm
Papilla -Incisal edges of maxillary central incisors : 6 mm
Mean vertical overlap : 2 mm

• Individual variations
• Not relevant in patients with severe resorption

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 PARALLELISM OF THE RIDGES

• Paralleling and a 5 degree opening in the

posteriors is acceptable as suggested by Sears.
Marked resorption of the ridges makes this rule
void.
• Natural, provided there has been no abnormal
change in the alveolar process such as a
previous advanced periodontal disease or gross
supra-eruptions.

• Most people – ridges are not parallel

Teeth lost at different times
Resorption pattern

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MEASUREMENT OF THE FORMER DENTURES

• Measurements are made from the borders of with a Boley

gauge.
• Correlated with the observations of the patient’s face
• Distance is too short or long – Corresponding change can be
made.

• Problems:
• Loss of the ridges under the dentures results in an increase in
interocclusal distance.

• Patients can shift the mandible, or the denture can be shifted

on its support to accommodate for errors in occlusion.

• Inaccurate adaptation of the denture base to the support

results in displacement of the denture
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PREEXTRACTION RECORDS
These data reveal the progressive changes which occur when the natural
teeth are extracted.

They provide information about –

• Occlusal vertical dimension
• Anteroposterior angle of occlusal plane
• Position and inclination of maxillary central incisors
• Horizontal and vertical overlap of each tooth.
• Length and width of teeth.

(A pre-extraction profile record. -J. Prosth. Dent. 45: 479, 1981)

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1. PROFILE RADIOGRAPHS
• Much used in research of vertical dimension of
occlusion
• Lateral skull radiographs before and after
extraction are compared.

Disadvantages:
• Radiation risks – So cannot be considered for
routine clinical use.
• Considerable time
• Unreliable-
-Inaccuracies that exist in the technique
-Inaccuracies in the method of comparing
measurements
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2.PROFILE PHOTOGRAPHS
• Made with the teeth in maximum occlusion
• Enlarged to life size
• Measurements of anatomic landmarks on the
photograph are compared with measurements
using the same anatomic landmarks on the face.
• These measurements can be compared when
the records are made and again when the
artificial teeth are tried in.
• Disadvantages :
Angulation of the photos might differ.
Photo enlargements cause inaccuracies.

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3.PROFILE
SILHOUETTES
• Lead wire adaptation along the
midline helps preparing a cardboard
cutout, which is preserved after
extraction.
• Repositioned to the face after the
vertical dimension has been
established at the initial recording
and/or when the artificial teeth are
tried in.

(A pre-extraction profile record. -J.

Prosth. Dent. 45: 479, 1981)

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4. CASTS OF TEETH IN OCCLUSION

• Practical method
• Measurements:
• - Incisive papilla and crest of the lower ridge
-Extended height of upper and lower buccal frena
-Hamular notch and retromolar pad

• Indicate the amount of space required between

the ridges for teeth of this size.

• Valuable in patients whose ridges are not

sacrificed during the removal of teeth or
resorbed during a long waiting period for denture
construction.
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5. RESIN FACE MASKS: SWENSON
(1959)-

• Acrylic resin face masks are made before

the extractions and later, when the patient
is edentulous, fitted on the face to see
whether the vertical dimension has been
restored properly.

Disadvantages:
• Requires a great deal of time
• Extensive experience with the use of facial
impressions and casts.
• Different topography of face in erect and
recumbent posture. 26
65

Swenson’s Complete Dentures, Boucher, Editor, Fifth edition

 6.FACIAL
MEASUREMENTS

a. To record the relation of the head to the

central incisors vertically and
anteroposteriorly by placement of a face bow
with auditory meatus plugs and with
spectacle suspension.

b. To record the distance from the chin to the tip

of the nose by means of a pair of calipers or
dividers before the teeth are extracted.

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c.Willis guage.
• Pupil of the eye to rima oris = anterior nasal spine to inferior
border of mandible.

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J Prosthet Dent 2004;91:59-66.

d) Equal- thirds concept :
The face can be divided into equal thirds – the forehead, the
nose and the lips and chin.

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 PHYSIOLOGICAL METHODS
1.PHYSIOLOGICAL REST POSITION
• Indication of the appropriate vertical dimension at rest

• Rest vertical dimension – Occlusal vertical dimension= Interocclusal

distance

• Interocclusal distance : 2-4mm when observed at the position of first

premolars.

• May not
65 be an exact guide 30
• METHOD :
-Patient relaxed, with trunk upright and
the head unsupported.

-After insertion of the occlusal rims the

patient should be asked to swallow and
let the jaw relax.

-The lips are parted to reveal how much

space is present between the occlusal
rims.

- The interocclusal distance should be 2-

4mm at the premolar region.
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->4mm- occlusal vertical
dimension is too small.
-< 2mm- occlusal vertical
dimension is too great.

- Occlusion rims are adjusted

until adequate interarch space
is obtained and patient
comfort and phonetic and
esthetic considerations are
satisfactory.

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2.PHONETICS
• Listening to speech sound production and observing the relationships of teeth during
speech.

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1. CH, S, AND J –
• Bring the anterior teeth close together.
• Lower incisors should move forward to a position nearly
directly under and almost touching the upper incisors.

• If anterior teeth touch when these sounds are made or if the

teeth click together during speech, the vertical dimension is
too great.

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 2. Have the patient repeat the name ‘Emma’ or ‘ Om’ until he is
aware of the contacting lips as the first syllable ‘m’ is
pronounced. When the patient has rehearsed this procedure,
ask him to stop all jaw movement when the lips touch. At this
time measure between the two points of reference.

• 3. Engage the patient in a conversation that will divert his

attention from conscious participation in the procedure. A
pause in the speech, followed by relaxation as indicated by a
drop of mandible, is an indication for another measurement.
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 4.CLOSEST SPEAKING SPACE: SILVERMAN
• Measures the vertical dimension when the mandible
and muscles involved are in physiologic function of
speech.

• The occlusion rims are placed in the mouth and the

height is adjusted until a minimum of 2 mm space exists
when the patient pronounces the letter “S”.
• Closest speaking space – vary from 0-10mm

• Disadvantage: Patient who has an 8-10mm closest

speaking
65
space will require other means for 36
determination of the vertical dimension.
 5. THE ‘F’ OR ‘V’ AND ‘S’ SPEAKING ANTERIOR
TOOTH RELATION: POUND AND MURRELL

‘f’ and ‘v’ sounds - The incisal edges of the

maxillary anterior teeth create a seal on
the moist area of the vermilion border of
the lower lip.

• ‘s’ - The position of the mandibular anterior

teeth is determined when the patient says
words beginning with ‘s’. When the ‘s’ sounds
are articulated, the mandible moves forward.
The incisal edges of the anterior teeth do not
make contact.
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3.ESTHETICS
• Labial surfaces of the occlusion rims
should be contoured to replace or
restore the tissue support provided
by the natural structures.

• If lips are not properly supported

anteriorly- tendency to increase the
vertical dimension is great- leads to
increased lower face height.

• Recent evidence – this method is

unreliable
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4.FACIAL EXPRESSION
• 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 the eyes and over the chin will
be relaxed.
• Relaxation around the nares reflects
unobstructed breathing.
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 5.SWALLOWING THRESHOLD

• Powell and Zander(1965), Boucher (1955)

and Shanahan (1955)
• Teeth come together with a very light
contact at the beginning of the swallowing
cycle.
• Highest point of jaw during deglutition =
VDO
Technique:
• Build cones of wax on the lower denture
base in such a way that they contact the
upper occlusion rim when the jaws are
opened65too wide. 40
• The flow of the saliva is stimulated by
food, such as a piece of candy.
• Repeated action of swallowing the saliva
will gradually reduce the height of the
wax cones to allow the mandible to reach
the level of occlusal vertical dimension.
• Length of the time to complete this
action and the relative softness of the wax
cones will affect the results. (The consistency of the the swallowing
technique in determining occlusal vertical
• No consistency in the final vertical relation in edentulous patients - J
positioning of the mandible has been Prosth. Dent., 36: 159, 1976)
found.

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 6.TACTILE SENSE PATIENT
A. PERCEIVED COMFORT

• Instruct the patient to stand erect and

open the jaws wide until strain is felt in
the muscles.

• When this opening becomes

uncomfortable , ask him to close slowly
until the jaws reach a comfortable ,
relaxed position.

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B) Lytle’s Neuromuscular perception - Lytle RB in 1964
• It relies on patient’s perception of different vertical height.
• A central bearing device is attached to accurately adapted
record base
• Bearing pin is adjusted beyond the rest position, pin is
then lowered by half turn. Patient has to signify over-
closure.
• Pin is raised again till excess opening is seen.
• Appropriate vertical relation is judged by the patient.
• Disadvantage :
• it cannot be used in patients with poor neuromuscular
coordination.
• Presence of foreign objects in the palate and the tongue
space.
• Conflicting65 results on the precision of this method 43

Lytle RB, Vertical relation of occlusion by the patient's neuromuscular

perception, Volume 14, Issue 1, January–February 1964, Pages 12–21
 7. POWER POINT ( BOOS BIMETER , 1940):
• Attach the bimeter to an accurately adapted mandibular
record base.
• Attach a metal plate in the vault of an accurately adapted
maxillary record base to provide a central bearing point.
• Adjust the vertical distance by turning the cap.
• The gauge indicates the pounds of pressure generated
during closure at different degrees of jaw separation.
• When the maximum power point is determined, lock the
set nut.
• Make plaster registrations and transfer the cast to an
articulator.
• Disadvantage: Such a device offers no more accuracy than
Niswonger’s or Silverman’s method.
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8.WAX OCCLUSION RIMS
• 1.Establish the vertical dimension at rest

• 2.Maxillary occlusion rim contoured to the tentative

occlusal plane is not altered unless absolutely necessary.
When they must be , reduce the rim distal to the cuspid
and retain the guides for positioning the anterior teeth.

• 3.Make the interocclusal distance approximately 3-4 mm

less than the interocclusal distance at rest position.

• 4.Thinly coat the maxillary occlusion rim with petrolatum.

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• 5.Soften a roll of baseplate wax in a
waterbath at 130o F and contour it in a
triangular shape with the base on the
occlusion rim and attach it to the
occlusal surface of the mandibular
occlusion rim.

• 6.Seat the mandibular record base in

the mouth and place the tips of the
index fingers bilaterally on the buccal
flanges in the area of the second
bicuspids to assure that the record base
is stable when the jaw is moved.
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• 7.Request the patient to retrude the
mandible and close on the back
teeth but to stop closing the jaw
when he feels that the closure is
sufficient.

• 8. Allow the wax to harden before

removing the tentative record from
the mouth.

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• 9.Reinsert the record and have
the patient close to maximum
occlusion. Measure the distance
between the points of reference
and compare with the
measurements made with the
mandible at rest.

- If the measurement is less than the

measurement at rest and the
baseplate wax is not penetrated
through to make occlusion rim
contact,
65
the record is acceptable. 48
 Niswonger’s method
• The camper’s 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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 Preparing for evaluation

• Relate the mandibular cast to the face-bow mounted

maxillary cast and attach the mandibular cast to the
articulator with plaster.

• Orient the plane of occlusion and arrange the anterior and

posterior artificial teeth to meet the functional and esthetic
requirements in centric occlusion.

• Contour the wax in the form of the finished denture.

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 Evaluating vertical dimension
Patient’s tactile sense:
• Place the trial dentures in the patient’s mouth.

• Instruct the patient to open and close until the teeth contact.

• Ask the patient if the teeth appear to touch too soon, if the jaws
seem to close too far before they touch, or if the teeth feel just
right.

• This
65
method is not very effective with senile patients or with those 52
who have impaired neuromuscular coordination.
Swallowing followed by relaxing

1.With the dentures in place instruct the patient to wipe the lips with the tip
of the tongue, swallow and let the shoulders drop in a relaxed position.

• If the teeth are together it can indicate that no interocclusal distance

exists.

2.Two small cones of a soft wax are placed, one in each central sulcus of the
mandibular first molars.

• Encourage the patient to swallow several times.

• If65the vertical dimension of occlusion is correct, the wax will be penetrated 53

and reduced to tooth contact.

 Phonetics

• Three, thirty-three : There should be enough space for the tip of the
tongue to protrude between the anterior teeth.

• Fifty-five : Incisal edges of the maxillary central incisors should

contact the vermilion border of the lower lip at the junction of the
moist and dry mucosa.

• Emma and Mississippi : Teeth should not contact.

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 Effects of increased vertical dimension
• Discomfort to the patient.

• Trauma and pain under the basal seat areas of dentures: The jarring
effect of the teeth coming into contact sooner than expected may not
only cause discomfort but in most cases it will also cause pain owing to
the bruising of the mucosa

• Loss of free way space : Muscular fatigue of any one or group of muscles
of mastication. In turn results in annoyance from the inability to find
comfortable resting position.

• Clicking sound : When occlusal vertical dimensions is increased, opposing

cusp will frequently meet each other producing an embarrassing clicking
55
sound. 65
• 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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 Effects of decreased vertical relation
Inefficiency : Pressure which is possible to exert with teeth in
contact decreases considerably with over closure because the muscles of
mastication acting from attachments have been brought closer together.

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.

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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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 Costen’s 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 overT.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 59
65
Dent, Vol 41, 6, Jun 1979, Pages 636–643
 REFERENCES

65 60
 Reestablishment of Occlusal Vertical Dimension in Complete Denture Wearing
in Two Stages
A 65-year-old woman came to a Dental School, Brazil, for assessment of a new complete denture.
The complete dentures were fabricated 23 years ago and her principal complaint was poor esthetics and ear pain.

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Case Reports in Dentistry. 2015;2015:1-5.

 The Study of the Effect of Altering the Vertical Dimension of
Occlusion on the Magnitude of Biting Force
• Aim: To develop a device capable of measuring the biting force generated during maximum
biting, during a change in VD and to determine, the relationship between the VDO and the
biting force.

• Materials and Methods: Indigenously fabricated electronic gnathodynamometer was used

to record biting force of 10 individuals at altered VD. The range of alteration was chosen from
increased 7.5 mm to decreased 4.5 mm and established VDO as base line.

• Results: Bite force was maximum at the VDO in edentulous subjects. Maximum biting
force recorded at VDO was reduced with subsequent increase or decrease in VD.
• Clinically highest biting force could act as an aid in determining and verifying VDO for
edentulous patients
65 62

Journal of International Oral Health 2015; 7(11):1-5

 Reliability of determining vertical dimension of occlusion in
complete dentures: A clinical study.
• Objectives :1. To assess the reliability of the conventional
methods in obtaining vertical dimension. 2. To analyse
changes in morphologic face height after extraction. 3. To
assess the reliability of measuring base of nose to chin
distance in obtaining vertical dimensions.

• Results: Nose-chin measurement has a significant corelation

with cephalometric measurements, hence it is found to be a
very effective pre extraction aid in determining vertical
dimension. However, reliability of pre extraction records in
long period of edentulousness is limited. The conventional
methods used to determine the vertical dimension are not
reliable
65 63

The Journal of Indian Prosthodontic Society. 2006;6(1):38.

 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.

• Several methods should be used to verify the vertical

dimension and there is no one single best method to do
so.

65 64
 REFERENCES AND CROSS REFERENCES

1. Prosthodontic treatment for edentulous patients : Boucher 9th Edition

2. Textbook of complete dentures : Charles M. Heartwell Jr., Arthur O Rahn, 4th and 5th Edition
3. Marin D, Leite A, de Oliveira Junior N, Compagnoni M, Pero A, Arioli Filho J. Reestablishment of Occlusal
Vertical Dimension in Complete Denture Wearing in Two Stages. Case Reports in Dentistry. 2015;2015:1-5.
4. Gosavi SS, Ghanchi M, Patil S, Sghaireen MG, Ali AH, Aber AM. The Study of the Effect of Altering the
Vertical Dimension of Occlusion on the Magnitude of Biting Force. Journal of International Oral Health.
2015 Nov 1;7(11):110.

65 65
 REFERENCES AND CROSS REFERENCES

5. Bhat VGopinathan M. Reliability of determining vertical dimension of occlusion in complete

dentures: A clinical study. The Journal of Indian Prosthodontic Society. 2006;6(1):38.
6. Irving M. Sheppard, Stephen M. Sheppard, “Vertical dimension measurements”, JPD 1975, 34(3) :
269 – 277
7. A.J. Turell; “Clinical assessment of vertical dimension”, JPD 1972, 28(3) : 238 – 246
8. Silvermann MM; “The speaking method in measuring vertical dimension”, JPD 1953, 3(2) : 193 –
199
9. Swerdlow H; Vertical Dimension literature review, J Prosthet Dent March April 1965, Vol 15, no. 2.
241-247.

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