Vertical jaw relation in complete denture

VERTICAL JAW RELATION
PRESENTED BY – DR. SHAILJA SHARDA
1-MDS
SEMINAR 3
1 2 3 4 5

CONTENTS
1
INTRODUCTIO
N
2
CLINICAL
SIGNIFICANCE
S OF JAW
RELATION
PHYSIOLOGIC
REST
POSITION AND
THEORIES
CLASSIFICATION MECHANICAL
AND
PHYSIOLOGICAL
METHODS
EFFECTS OF
DECREASED
VERTICAL
DIMENSION
CONCLUSION
PHYSIOLOGIC
REST
POSITION AND
THEORIES
PHYSIOLOGIC
REST
POSITION AND
TIES
REFRENCES
EFFECTS OF
INCREASED
VERTICAL
DIMENSION

• The main objective of prosthetic dentistry is to restore the missing dental and oral
structures in such a way that there is harmonious relationship between the teeth,
bones, joints and muscles.
INTRODUCTION
• In case of edentulous patient all the tooth guidance is lost.
• So in order to construct the complete denture, prosthodontist should discover the
relations of the mandible to the maxilla, when natural teeth were present.
• As the rest position of mandible remains fairly constant for reasonable period of
time after the loss of teeth, it is important in determining the vertical relation
during jaw relation records.
3

Vertical
Relations
Horizontal
Relations
Orientation
Relations
Maxillomandibular relations are of 3 Types:
4

DEFINITIONS 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.
(GPT8)
The vertical jaw relations are those established by the amount of separation of the
two jaws in a vertical direction under specified conditions.
(Boucher)
5

VERTICAL DIMENSION AT REST
/PASSIVE VERTICAL DIMENSION
It is the vertical separation of the jaws when the opening and
closing muscles of the mandible are at rest in tonic equilibrium
(Heart well).
6
Head should be in
upright position

(Heart well).
7
Head should be in
upright position
Muscles in
equilibrium in tonic
contraction

(Heart well).
8
Head should be in
upright position
Muscles in
equilibrium in tonic
contraction
Condyles in neutral
unstrained position

VERTICAL DIMENSION OF
OCCLUSION /ACTIVE VERTICAL
DIMENSION
The distance between two selected anatomic or marked
points when in maximal intercuspation position. (GPT
9).
FREEWAY SPACE/INTER-OCCLUSAL SPACE
VDR- VDO 9

Physiologic Rest Position
The postural position of the mandible when an individual is resting
comfortably in an upright position and the associated muscles are in a
state of minimal contractural activity. (GPT 8).
• The mandible is said to be in its physiologic rest position when all the
muscles that close and open the jaws are in a state of minimal tonic
contraction only to maintain posture. (Boucher).
12

PHYSIOLOGIC REST POSITION-HYPOTHESIS
• 1st hypothesis (active ): muscles - minimal contraction to maintain posture of
mandible
• 2nd hypothesis (passive): elastic elements of jaw musculature & no muscle
activity,-balance the influence of gravity.
Studies have shown evidence of EMG activity in patients at rest position.
• Current concensus : physiologic rest position= actively determined.
• Rest position 2 to 10mm below maximum intercuspation has been recorded.
• So,its more accurate to refer to a range of posture rather than a single rest
position-RANGE OF POSTURE
Prosthodontic treatment for edentulous patients: 12th ed, Boucher.
13

Significance of Physiologic Rest Position
• It is a measurable distance,
• A repeatable reference within an acceptable range, and
• A useful reference when determining the vertical dimension of occlusion.
Textbook of complete dentures: 5th ed by Arthur O. Rahn and Charles M. Heartwell.
17

METHODS TO MEASURE IT
FACIAL
MEASUREMENTS
TACTILE
SENSE
MEASUREMENT
OF
ANATOMICAL
LANDMARK
SPEECH
FACIAL
EXPRESSION

ACCORDING TO SWENSON:
I Ridge relation
 Distance of incisive papilla from mandibular incisors .
 Distance of Incisive papilla from crest of lower ridge.
 Esthetic values
 Esthetic values
II. Measurement of Former Dentures
Classification of methods of Recording
Swenson’s Complete Denture. Fifth Edition. Pg-156-157
23

IV. Pre-extraction records
V. Boos Bimeter
VI. Wright (interpupillary distance)
VII. Phonetics & Esthetics as guides
VIII. Swallowing threshold
24

Mechanical methods
Pre-extraction records
 profile radiographs
 casts of teeth in occlusion
 facial measurements
 ridge relation
 measurement of ridges
Physiological methods
 phonetics
 esthetics
 swallowing threshold
 tactile sense and patient
percieved comfort
ACCORDING TO BOUCHER
Boucher’s textbook.12th edition pg- 274-282
25

According to Sharry
 Pre-extraction determination
 Post extraction records
27
Niswonger’s method
Power point / Bimeter / Boos method
Concept of equal third
 Will’s measurements
 Electromyography
Lytle Method (Neuromuscular perception)

WHICH ARE THE PRE -EXTRACTION
RECORDS USED FOR DETERMINING
VERTICAL JAW RELATION?
28

Profile Radiographs
• Is a useful preextraction record
• A 1:1 ratio of cranium to image radiograph is obtained with lateral skull film -
made before and after extraction, when mandible assumes physiological rest
position or centric occlusion and measurements are made between bony land
marks of maxilla and mandible
• Later used as reference - patient becomes edentulous – present radiograph is
compared with the previous one.
MECHANICAL METHODS
Clinical assessment of vertical dimension- JPD 2006,96;79-83

• Questionable.
• Not practical for routine use
• Frequent exposure to irradiation
• Can be used for research purpose
• Constancy of rest position and occlusal vertical height from
dentulous to edentulous condition is disputed.
• Not applicable on patients with any congenital and acquired
Orofacial deformity, facial asymmetry or patients not willing to
undergo radiography

Profile photographs:
• Profile photographs are made with the teeth in maximum occlusion.
• Enlarged to life size.
• Measurements of anatomic landmarks is done - before and after extraction - on
photographs
31
Angulation of the photographs might differ with patient’s posture.
Accuracy doubtful - Enlargement may cause some inaccuracies.
Can serve as guide to compare the fullness of the face

Facial Measurements
Goodfriend suggested that the distance from the pupil of the eye to
junction of the lips equal to that from the subnasion to the gnathion
32

McGee correlated VDO with 3 facial measurements which he claimed remain
constant throughout life. These were:
• the distance from the center of the pupil of the eye to a line projected laterally from
the median line of the lips;
• the distance from the glabella to the subnasion; and
• the distance between the angles of the mouth with the lips in repose.
According to him atleast two of these three measurements will be invariably equal
GLABELLA
SUBNASION

Articulated casts
• Articulated casts of patient before and after the extraction are compared.
• Simple method of recording -vertical overlap relation , size and shape of the teeth
 Cannot be used where there is a long waiting period for fabrication of
denture after extraction.
 Not useful if there is excess loss of bone during extraction

Measurement of former dentures
• Boley’s gauge
Use of a patient’s old complete denture to determine vertical dimension of occlusion. Majid Bissasu. JPD
2001: 85(4); 413-414.
Several reasons for not accepting the measurements :
• Residual ridge resorption under the denture increases the IO distance
• Can be used only if the patient’s old denture is available
• Can be adopted only if existing VDO and occlusal plane are within normal limits

Profile tracing (Lead wire adaptation)
• A piece of soft lead wire…
• Moulded to contour the face starting from the eye brow to just below the chin
along the midline.
36
Not simple ..wire may bend during storage
Possibility of change in the facial contour and vertical height subsequent to
extraction of teeth should be considered

The Dakometer
• This instrument records both the VDO and
position of upper central incisors.
• In most cases recording can be obtained with an
error range of 1mm.
• Place on patient face when the patient is in
maximum intercuspation.
• Edge moves to engage incisal edge of maxillary
teeth…record the measurement .
• The Dakometer is reported to be an accurate
measuring device.

Willis gauge
• Used for recording vertical height before extraction.
• Upper part is place in contact with the base of the nose.
• Lower member is moved on the slide until it touches the lower border of the chin.

• Difficult to generate anthropometric measurements in all patients .
• Measurements are difficult to obtain as there are no precise measurable
fixed points .
• Soft tissue landmarks vary.
• Difficult to fix an exact point on the chin to measure the distance .

Acrylic Resin Mask
• By Swenson
• Acrylic resin face mask is made before the extraction .
• Hydrocolloid impression of patients face is made ..this is reinforced with plaster
before it is removed from the face ..poured in stone ..2-3mm baseplate wax is
adapted ..this wax mask is the processed with clear acrylic resin
Complete denture prosthodontics, 3rd ed by John J. Sharry.

• Cumbersome method - More time and experience required .
• Hydrocolloid material requires precise procedure large quantities must be
warmed to the correct temperature and then painted on the face.
• The face assumes a different topography in the erect posture from that in
the recumbent or semi recumbent position.
• In supine position – VDR cant be accurately determined
• Less accurate than profile soft wire tracing method
• Displaces skin with inaccuracy of up to 2mm

RIDGE RELATION
• Victor Sears
• Paralleling of the maxillary and mandibular ridges plus 5-degree opening in the
posterior.
• Because the clinical crowns of the anterior & posterior teeth have nearly the
same length, their removal tends to leave the residual alveolar ridges nearly
parallel to each other
•
Prosthodontic treatment for edentulous patients: 12th ed, Boucher.276

• In most people the teeth are lost at different times and so by the time the
patients are edentulous, residual ridges are no longer parallel
• Edentulous ridges of the mandible and maxillae will become progressively
more discrepant from the standpoint of width .
• Difficult to visualize parallelism intraorally

Distance of incisive papilla from mandibular incisors
Questionable use:
• In absence of lower anterior teeth.
• Patients with severe resorption.
• Average measurements – subjected to variations
Prosthodontic treatment for edentulous patients: 12th ed, Boucher. 276

Niswonger’s method
• Based on Niswonger’s concept that mandible moves 1/8 inch (3mm)
upward from rest position to centric occlusal position.
Most commonly used…
• Simple
• Accurate
Manual on maxilla- mandibular relations, face bow and articulators, E.G.R Solomon
47

• The patient is seated so that ala-tragus line is parallel to floor.
• Two marks ….
• Swallow and relax…
• Distance is measured….

Power point or Bimeter or Boos method :
• device registers the biting force at varying degrees of jaw separation.
• Suggested by Ralph Boos (1940) .
• Attach the bimeter to mandibular record base.
• And a metal plate in the vault of maxillary record base.
Clinical assessment of vertical dimension- JPD
2006,96;79-83

• The gauge indicates pounds of pressure generated during closure at different
degrees of jaw separation.
• Vertical height is adjusted by altering occlusal rims till maximum biting force
pressure is obtained

• Time consuming
• The vertical level of maximum closing power is indicated only on
the effective parallelism of the ridges.
• It was reported that this didn’t represent an occlusal position but
rather represented rest position .Since then it has been shown
that vertical dimension has no definite relationship to the
powerpoint. Neither the occlusal nor rest position does
necessarily coincide with the powerpoint. Therefore use of power
point as reference in vertical dimension is not always accurate.
Clinical measurement and evaluation of vertical
dimension JPD 2006, 95; 335-9

WILLIS MEASUREMENTS
• Willis gauge.
• At VDR , A=B
• Soft tissue landmark measurements are debatable.
• Also willis gauge is not as precise as Dakometer, pointed steel dividers and
precision calliper.

ELECTROMYOGRAPHY
• Based on fact that minimal muscular activity occurs when the mandible is in the
rest position
• Produces more consistently reliable determination of VDR than conventional
methods
• Uses a special device that measures the tone of masticatory muscles, when the tone
is at its least, this means these muscles and jaws are in rest position
Rest position: An Electromyographic and Clinical Investigation. JPD 1962:12(5);895-911.

• This appears simple – but not a practical method
• The equipment is too expensive.
• Cumbersome procedure .
• Requires trained personnel.
• It may not be practical to install an electromyogram in the dentist
office for the purpose of recording vertical dimension
• Inability of the patient to relax ,cooperate and understand
instructions are other difficulties
• Ramford EMG study indicated resting range for muscles rather then a
position. Clinically determined Rest position dosent often agree with
minimal muscle activity as determined electromyographically.

TENS (Transcutaneous Electrical Neural Stimulation )
Special device produces electric current to stimulate nerves
For recording VD, ultra low frequency TENS is used.
Electrodes are applied over coronoid notch area.
Current is passed to stimulate contraction of muscles via cranial nerves.
EMG activity before and after application of current is recorded.
VDR is achieved when muscles are at their lowest level of activity.
Rest position: An Electromyographic and Clinical Investigation. JPD 1962:12(5);895-911.

• Researches have indicated that rapid adaptations take place after the
changes in vertical dimension, leading to another rest position and a
change in IOD.
• Therefore rest position alone is not a reliable basis.
• Should be combined with ….. Phonetics, esthetics and patient comfort.

PHONETICS
• Phonetic tests of VD include :
Prosthodontic treatment for edentulous patients: 12th ed, Boucher.pg 278-279
Listening to speech sound production
Observing relationship of teeth during
speech

Methods:
• During production of “M” sound, lip contact is passive.
• So it can be used as an aid in obtaining correct VD
• F and V – requires adequate freeway space for pronunciation
• When patient is asked to pronounce two words thick-thin alternatively, the tongue
usually fills into the gap between upper and lower occlusal surface. This is again
useful to judge the adequacy of free way space.
• During pronunciation of Mississipi, Fifty five- appropriate freeway space is
checked .
If teeth click= VD is more
If pronounced as sh, or with a whistling sound= VD is reduced.
Phonetic method only serves as a check to verify dimension
obtained by other methods and to judge extent of available freeway space.

• SILVERMEN’S METHOD OR SILVERMEN’S
CLOSEST-SPEAKING SPACE METHOD.
• Meyer Silvermen (1952)
• production of the certain sounds like ‘S’, ‘Yes’, ‘Miss’, ‘Buzz’ brings the
anterior teeth very close together.
• When correctly placed, the lower incisor are moved forward to a position
nearly directly under the upper central incisors and almost touching
them.

PHONETICS IN COMPLETE DENTURE –A
REVIEW
DR. RENU GUPTA, DR. R.P. LUTHRA, DR. DEEPAK GAUTAM
• Phonetic tests while patients are producing sibilant sounds enable the dentist to identify the
smallest speaking vertical separation of the anterior teeth occlusal rims (Burnett, 1994). Silverman
(1952) affirms that the closest speaking space (CSS) of each individual is constant throughout life;
this would allow dynamic determination of the vertical dimension of occlusion (VDO) in both
dentate and edentulous patients.
• The `CSS Technique', has gained wide acceptance and has been used in clinical research (Pound,
1966, 1977; Gillings, 1973). Morrison (1959) suggested using the words sixty-six and Mississippi.
• Clemencon (1967) believes it is possible to increase the CSS by thickening the resin palatal vault of
a complete denture. This procedure could allow an increase of the VDO, in cases in which it is too
low from the aesthetic stand-point, avoiding contact between opposing teeth during speech.
• The clinical rest position (CRP) is a commonly used reference point in the determination of OVD
and when in this position there is a variable space between the maxillary and mandibular teeth, or
alveolar ridges, which is referred to as the interocclusal distance.
International Journal of Healthcare Sciences Vol. 4, Issue 1, pp: (373-377), Month: April 2016 - September 2016

• “Silverman” suggested that incorrect determination of the vertical dimension of occlusion
and improper placement of anterior teeth frequently results in a lisp or substitution of the
/th/ sound for the /s/ sound.“ Tanaka” found that in edentulous patients the placement of a
denture resulted in overall improvement of speech with time. He noted that the sounds most
frequently in error were the sibilant sounds and that palatal contour can affect certain
speech sounds.
• “Boucher” and “Allen” reported that edentulous patients tend to return to normal speech
patterns relatively soon after insertion of dentures, whereas “Troffer” and “Beder” found that
normal speech patterns were not observed weeks after the insertion of immediate dentures.
• Fymbo (1936) pointed out that defective speech is most frequently associated with increased
vertical dimension which may result in difficulty in pronouncing sounds like b, m, p, f, v.
Landa (1947) recommended various phonetic tests to determine proper vertical dimension
using sounds such as s, c, z.

• Silverman (1956) stated that sibilant sound “s” as a mean for determining the
correct vertical dimension. He established the closest speaking space‖ and used this
as clearance area between the dentures. The bilabial sounds like “m” is useful in
determining the vertical dimension, when this sound is pronounced there will be
passive contact between the upper and the lower lip, which aid in obtaining the
correct vertical dimension.

• Useful as:
1. A pre extraction record.
2. To determine VD.
3. To verify VD

1. As a pre extraction record.
Patient is seated in upright position and made
to close in centric relation.
Draw the centric occlusion line with a sharp
pencil on a lower anterior tooth at the
horizontal level of the incisal edge of the
opposing upper anterior tooth.
This line is called centric occlusion line.
The speaking method in measuring vertical dimension. JPD 2001,85(5); 427- 431.

Patient now pronounces words containing an end
sibilant such as yes, miss, buzz..
Draw the closest speaking line on the same lower
anterior tooth at the horizontal level of the upper
incisal edge.
• The distance between the centric occlusion line (lower
line) and the closest speaking line (upper line) is called
the closest speaking space.
• Usually 2-3 mm(Thompson),2-
5mm(sicher),3mm(Niswonger),3mm(Pleasure).
The speaking method in measuring vertical dimension. JPD 2001,85(5); 427- 431.

2. To determine VD after extraction
• Occlusal rims are adjusted until a minimum of 2mm of closest speaking space
exists when the patient pronounces ‘s’ or other sibilants.
3. To verify JR
•Require fair degree of judgement to obtain and assess closest
speaking space.
•Applicable mostly in class I JR.
•Patient’s speech may be strained due to the presence of occlusal
rims.

SWALLOWING THRESHOLD
• Thomas 1955
• The position of mandible at the beginning of swallowing act has been used as guide
for determining VDO.
• Technique: Uses soft wax cones on the rims; this induces the patient to salivate and
gradual swallowing will reduce height to VDO
swallowing may be used only as a guide to the VDO.
Previous dentures if any should be removed for some time before recording the
VDO to obliterate the memory of acquired neuromuscular patterns.

COMPARISON OF FOUR METHODS TO DETERMINE REST POSITION OF THE
MANDIBLE. ALLYN G. WAGNER. JPD 1971:25(5); 506-514.
• REST 1,M,M,M, SWALLOW, OPEN-CLOSE, and REST 2.
• ….in order to compare the rest vertical dimensions from the two separate REST
trials.
• Electronic and electromagnetic equipment was used to record the readings.
• The REST method, based on natural relaxation, appeared to be an acceptable
method to determine the rest position, because the measurements presented less
high and low readings.
• The M,M,M method tended to produce a large rest vertical dimension and the
swallowing method a smaller one.

RELIABILITY OF DIFFERENT FACIAL MEASUREMENTS FOR
DETERMINATION OF VERTICAL DIMENSION OF OCCLUSION IN
EDENTULOUS SUBJECTS, USING ACCEPTED FACIAL DIMENSIONS
RECORDED FROM DENTULOUS SUBJECTS.J INDIAN PROSTHODONT
SOC. 2014 SEP;14(3):233-42
• A study was done to evaluate the reliability of different facial measurements for
determination of vertical dimension of occlusion in edentulous subjects using
accepted facial dimensions recorded from dentulous subjects.
• Glabella –subnasion, pupil-rima oris, outer canthus of eye to angle of mouth
distance ,chin-nose distance,subnasion-menton
• Conclusion- The outer canthus of eye to angle of mouth distance was found to be a
valuable adjunct in the determination of occlusal vertical dimension.

CAD/CAM technology has already made significant strides in the field of dentistry.
Recently, CAD/CAM technology has become commercially available for fabrication
of complete dentures through the introduction of AvaDent™ digital dentures by
Global DentalScience.
It is a system by which impressions, interocclusal records, and teeth selection can
be completed in one appointment. The dentures are then fabricated using CAD/
CAM technology and placed in the second appointment.
CAD CAM DENTURES
CAD/CAM technology: application to complete dentures. Loma Linda University Dentistry. Summer /
Autumn 2012. Volume 23, Number 2

CAD CAM DENTURES
Maxillary Anatomical Measuring
Device (AMD) showing wrench used to
move the adjustable lip support flange
Mandibular AMD with recording plate
and maxillary AMD with adjustable
stylus
CAD/CAM technology: application to complete dentures. Loma Linda University Dentistry. Summer / Autumn
2012. Volume 23, Number 2

Maxillary AMD filled with recording
material
Maxillary and mandibular AMD
placed fairly parallel to each other
CAD/CAM technology: application to complete dentures. Loma Linda University Dentistry. Summer /
Autumn 2012. Volume 23, Number 2

Occlusal vertical dimension being adjusted
with a centrally located adjustable stylus
Confirming occlusal
vertical dimension

AvaDent™ ruler attached to the
Maxillary AMD
Determining the appropriate occlusal
plane with AvaDent™ orientation ruler

CLINICAL SIGNIFICANCE AND
CHARACTERISTICS OF VERTICAL DIMENSION

INCREASED VERTICAL
DIMENSION
• Discomfort to the patient.
• Loss of free way space
• Clicking sound
• Elongated appearance of face
• Trauma and pain under the basal
seat areas of dentures.
• Difficulty in swallowing
Registration: Stage II —intermaxillary relations BRITISH DENTAL JOURNAL, VOLUME 188, NO. 11, JUNE
10 2000
DECREASED VERTICAL
DIMENSION
• Inefficient biting forces
• Cheek biting
• Facial distortion
• Angular chelitis (perleche)
• Pain in tempromandibular joint

CONCLUSION
• An accurate vertical limit of occlusion with provision for a desirable freeway
space in CD is of paramount importance.
• Several methods have been described to obtain vertical dimension of the
edentulous jaws, but no one particular method has proved to be completely
reliable by itself .A knowledge of most of them combined with clinical
judgement gives reasonable degree of accuracy and satisfaction .

REFERENCES
• Swenson’s complete dentures textbook.fifth edition
• Complete denture prosthodontics, 3rd ed by John J. Sharry
• Prosthodontic treatment for edentulous patients: 12th ed, Boucher.
• Text book of Complete dentures – 5th edition heartwell
• Role of Cephalometery in evaluation of vertical dimension-Pakistan
Oral & Dental Journal Vol 33, No. 1 (April 2013) 183
• Use of a patient’s old complete denture to determine vertical dimension of
occlusion. Majid Bissasu. JPD 2001: 85(4); 413-414.
• Establishing the vertical relation of occlusion. Brente L. Ward et al.
JPD;1963(3);432

• Registration: Stage II —intermaxillary relations BRITISH DENTAL JOURNAL,
VOLUME 188, NO. 11, JUNE 10 2000
• Reliability of different facial measurements for determination of vertical dimension
of occlusion in edentulous using accepted facial dimensions recorded from
dentulous subjects. J Indian Prosthodont Soc. 2014 Sep;14(3):233-42
• The speaking method in measuring vertical dimension. JPD 2001,85(5); 427- 431.
• Rest position: An Electromyographic and Clinical Investigation. JPD
1962:12(5);895-911.
• Clinical assessment of vertical dimension- JPD 2006,96;79-83
• Phonetics in complete denture – A Review. International Journal of Healthcare
Sciences Vol. 4, Issue 1, pp: (373-377), Month: April 2016 - September 2016
• CAD/CAM technology: application to complete dentures. Loma Linda University
Dentistry. Summer / Autumn 2012. Volume 23, Number 2

• A new technique to determine vertical dimension of occlusion from anthropometric
measurements of fingers.Ruchi et al. Indian Journal of Dental Research, 24(3),
2013

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