Original article

Determination of vertical dimension of occlusion in dentate

patients by cephalometric analysis – pilot study

Karine T. A. Tavano1, Paulo I. Seraidarian2, Dauro D. de Oliveira3 and Wellington C. Jansen2

1
Department of Operative Dentistry, School of Dentistry,Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG,
Brazil; 2Department of Prosthodontics, School of Dentistry, Pontifical Catholic University of Minas Gerais; 3Department of Orthodontics, School
of Dentistry, Pontifical Catholic University of Minas Gerais

Gerodontology 2011; doi: 10.1111/j.1741-2358.2011.00469.x

Determination of vertical dimension of occlusion in dentate patients by cephalometric analysis – pilot
study
Objectives: The concept of vertical dimension of occlusion (VDO) refers to a measure in the vertical plane
that establishes the relation between the maxilla and the mandible when the posterior teeth, both from the
maxillary and from the mandibular arches, are occluded, regardless of whether they are natural or pros-
thetic, healthy or restored. This measure is subject to change, and when this occurs, it can compromise both
the function and the facial aesthetics. This study proposed to develop a methodology based on cephalo-
metric analysis by studying the 31 lateral teleradiographs of adult, dentate individuals to determine the
VDO, based on bone structures that are not dependent on the presence or absence of posterior teeth. The
final goal was to make this application accessible to individuals who have undergone alterations of the
lower portion of the face.
Materials and methods: The cephalometric analysis of this study, called Seraidarian-Tavano, was verified
through facial angles (upper and middle angles) that, when correlated, determine the lower position of the
face.
Results: The analysis of results showed that no statistically significant difference between the angles
studied could be observed (superior angle 50.29 ± 3.35 e median angle 49.95 ± 3.37). In the same manner,
no variation in the results regarding gender in the measure of these angles could be observed.
Conclusion: This cephalometric analysis can be applied to determine the VDO, regardless of the presence
or absence of posterior teeth.

Keywords: cephalometric analysis, occlusal vertical dimension, complete denture, dental occlusion.

Accepted 6 October 2010

techniques described to determine the vertical

Introduction
The establishment or re-establishment of maxillo-
mandibular relations that have been altered over
time is currently the focus of many studies.
There is a consensus in the literature1–5 con-
cerning the position of the mandible in the hori-
zontal plane, which, in the final analysis, involves
assessment and procedures linked to the concept of
the centric relation and the central occlusion.
However, in the vertical plane, the literature still
remains divided on the issue, especially with regard
to those individuals who have suffered some form
of change in relation to the height of the posterior
teeth. This is exemplified by the large number of
dimension of occlusion (VDO), as well as the ver-
tical dimension of rest. In contrast, an even greater
number of scientific articles contest the validity of
these techniques, claiming to be empirical with
little credibility and no possibility of reproduction
or statistics that would validate the study1,6–8.
This search was described by Willis in 19302,9,
who proposed a methodology that attempted to
establish harmony among the upper, middle and
lower thirds of the face, by means of cultural
parameters for ‘harmonic faces’. Many authors
have developed studies aimed at establishing cri-
teria that would prove this correlation, as described
by Cerveira Neto3.

 2011 The Gerodontology Society and John Wiley & Sons A/S 1
2 K. T. Aguiar Tavano et al.

Predicting the inconsistency of these methodol-

ogies, Ricketts6, Donavan10, Posselt11, Coccaro and
Lloyd12, Monteith13, Orthlieb et al.1 and Brzoza
et al.14 researched measurement standards estab-
lished through radiographic techniques and ceph-
alometric analyses. However, to date, these have
not allowed for an individualised application
among those who have undergone alterations in
the VDO.
Given these considerations, the following ques-
tion remains: Is there a method that would be able
to determine the VDO in a reliable manner,
regardless of the presence of teeth, with statistical
significance?
This study proposed to develop a multidisciplin-
ary approach involving dental prosthetic and
orthodontics courses, in turn developing a tech-
nique with statistical credibility to determine the
VDO of any adult, dentate or edentulous.

Materials and methods

To carry out this research, 31 lateral teleradio-
graphs, 24 · 30 cm, were selected from the data
files of the Dental Clinics at the School of Dentistry
at Pontificia Universidade Catolica de Minas Gerais.
Inclusion criteria included adult individuals who
were dentate, with the exception of the third
molar, which had not undergone orthodontic,
surgical, reconstructive or orthognathic treatment
or restorative procedures on more than two pos-
terior teeth in each quadrant. These patients should
be classified as skeletal class I, given that the VDO
had been maintained. With regard to the radio-
graphic images, these should be performed
accordingly and at the appropriate contrast. In this
manner, seven male and 24 female individuals,
ranging from 18 to 48 years of age, were randomly
selected, with the specific request that these indi-
viduals would represent a diversity of ethnicities.
To obtain the designs, a sheet of vegetable paper
was attached to each of the radiographs using an
adhesive strip. Then, in a dark environment, under a
negatoscope, the anatomical points were marked
with a 0.3-mm graphite pencil in order to create the
designs described later in this text. A ruler, a square
and a cephalometric protractor (TP Orthodontics,
Quality Products) were also used. All designs were
performed by the same, previously calibrated oper-
ator. The same designs were redone under the same
conditions and at an interval of 15 days. Results
were analysed so as to verify the inter-examiner
error, that is, the reliability of the measurements.
The anatomical structures that were determined
and transferred onto the vegetable paper, which
Figure 1 Straight line design and the construction of the
Goc c point.
was placed over the radiographs, included the
following: frontal, orbital, palatine, mandibular,
maxilla, zygomatic and nasal bones, in addition to
the external auditive meatus and the pterygo-
maxillary fissure. In these bone structures, the
following anatomical points were determined
(Fig. 1)15:
1. Násio (Na): point located at the joining of the
frontal and nasal bones, in the median sagittal
plane;
2. Mentonian (Me): lowest point on the mandib-
ular symphysis curve;
3. Anatomic pore (Po): highest point of the external
auditive meatus;
4. Anterior nasal bone (ENA): the most anterior
point of the floor of the nasal airway, in the median
sagittal plane;
5. Orbital (Or): lowest point of the floor of the orbit;
6. In the images in which it was possible to identify
double points, the reference used for the design
was the average distance between the two points
found.
The next step was to perform the designs aimed
at determining the constructed planes and cepha-
lometric points (Figs 1 and 2):
1. Mandibular plane: straight line constructed
between the Menton and the lowest posterior point
traced in the region of the gonial angle;

 2011 The Gerodontology Society and John Wiley & Sons A/S

Figure 2 Straight line design and the construction of the
CF point.
2. Tangent to the posterior border of the ascending
branch of the mandible; straight line constructed
tangentially to the most distal point of the articular
condyle and the gonial angle connected to the
ascending branch;
3. Constructed gonio (Goc): located on the vertex
of the angle formed by the intersection of the
tangent to the posterior border of the ascending
branch of the mandible, together with the man-
dibular plane;
4. Frankfurt plane: straight line between the Po and
Or points; the Frankfurt plane in the teleradiograph
passes through the highest point of the external
border of the external acoustic meatus and through
the lowest point in the orbital margin.
5. Facial centre (CF): point marked on the posterior
wall of the pterygopalatine fissure, constructed
from a line that is perpendicular to the Frankfurt
plane;
6. Na–CF: straight line marked between the násio
points and the facial centre;
7. CF–ENA: straight line marked between the
anatomical points of the facial centre and the
anterior nasal bone.
After completing these steps, analysis called the
Seraidarian-Tavano cephalometric analysis was
started as proposed in this study to determine the
angles to be described.
 2011 The Gerodontology Society and John Wiley & Sons A/S
Determination of vertical dimension of occlusion 3
Figure 3 Construction of the upper angle.
First, the angle of the upper third of the face
called the upper angle (UA) was measured, using a
protractor and the Na–CF and CF–ENA, that is, the
Na–CF–ENA planes (Fig. 3), as a reference.
Next, with the centre of the protractor positioned
at the Goc point and the 0o line in the mandibular
plane, the value found in the UA (thus forming a
new angle called the transferred lower angle [TLA])
was calculated (Fig. 4). The upper edge of this
angle crosses the lower edge of the UA (CF–ENA
plane). At this intersection, a third angle was
formed, called the middle angle (MA) (Fig. 5).
After formulating the third angle, the parallelism
between the CF–ENA and Goc–Me, as shown in
Fig. 6, could be observed. The values obtained in all
31 designs of the UA and MA were duly noted for
later comparison between the cephalometric and
statistical analyses.
With the aim of comparing this new methodol-
ogy, each of the 31 selected teleradiographs were
submitted to previous scientifically proven analy-
ses, such as that from Legan and Burstone16 and
from McNamara17, other authors who also propose
vertical measurements of the face.
The data obtained were duly noted and later
submitted to statistical analysis, and the statistical
test used to compare the measures of the middle
and upper angles was the paired t-test, and to verify
whether there was in fact a difference between the
4 K. T. Aguiar Tavano et al.
Figure 4 Construction of the transferred lower angle.
Figure 5 Determining the middle angle.
measures of the angles regarding the type of angle
(upper and middle) and the gender (male and
female), the analysis of variance (ANOVA) test was
performed.
Figure 6 The parallelism between the CF–ENA and the
Goc–Me, confirmed by means of the equal internal
alternating angles.
Results
This study was able to determine the UA of all 31
radiographs studied, with the value of these cal-
culated between 45º and 57º, with an average
value of 50.29º. It should be noted that in male
subjects, these values ranged from 47º to 55º, with
an average of 50.8º, while in female subjects, these
values ranged between 45º and 57º, with an aver-
age of 50.12º; that is, no statistical variation
between the genders could be observed. Given
these facts, the TLA was determined by the trans-
ference of values and, as expected, as this was
transferred in a simple manner, did not present any
difference when compared to the UA. Considering
these two angles, one can also determine the third
angle (MA) in all of the teleradiographs. The values
found are described in Table 1.
Given these angular values, a cephalometric
analysis could be performed, aimed at verifying
the correlation that exists between the proposed
angles. A statistical analysis was applied to compare
the measures of the UA and the MA of each indi-
vidual studied. In the descriptive statistics between
the UA and MA, as shown in Table 2, the two
angles did not present significant differences. The
statistical test used to compare the measures of the
 2011 The Gerodontology Society and John Wiley & Sons A/S
 Determination of vertical dimension of occlusion 5

Table 1 Cephalometric values of the Seraidarian-Tavano Table 3 Values from the paired t-test for the upper and
analysis middle angles

Patient Age/Gender Upper Angle Middle Angle Standard

N Mean deviation SE mean
1 43/F 45º 45º
2 22/F 48º 49º Upper Angle 31 50.2903 3.3511 0.6019
3 32/F 45º 45º Middle Angle 31 49.9516 3.3723 0.6057
4 21/M 53º 54º Difference 31 0.338710 1.090773 0.195909
5 33/F 46.5º 46º
6 25/F 52.5º 53º 95% CI for mean difference: ()0.061389; 0.738808).
7 21/F 55º 53º p-value = 0.094.
8 39/F 53.5º 52º Source: Research data
9 34/F 48º 47.5º
10 28/M 52º 52.5º (male and female), the analysis of variance (ANOVA)
11 41/F 47.5º 47.5º test, with a 95% CI, was performed (Table 4).
12 30/F 45º 45º The ANOVA described earlier detected no influ-
13 29/F 46º 45º
ence from any of the factors; the p-values (in bold)
14 43/F 52.5º 50º
15 28/M 55º 55º
were >0.05; thus, we can conclude that there was
16 24/F 50.5º 50.5º no difference in the measurements with regard to
17 21/F 51º 49º gender or angle.
18 38/F 55º 54º
19 26/M 47º 46º
20 22/M 51.5º 50º
Discussion
21 40/F 48º 48º The loss of teeth and, consequently, the provision
22 28/F 57º 58º of full prosthetic dentures have always generated
23 20/F 54º 54º great interest, for patients as well as for profes-
24 20/M 48º 50º sionals who work in the area. This is attributable
25 27/F 51º 48º
mainly to the fact that non-reestablishment of the
26 18/F 54º 54º
27 18/F 51.5º 51º
height of the lower third of the face significantly
28 21/M 49.5º 50º compromises function, facial aesthetics and, con-
29 27/F 49º 49º sequently, the stomatognathic system, thus influ-
30 33/F 48,5º 48.5º encing the patients’ quality of life4. The present
31 48/F 49º 49º study attempted to develop a methodology that
could be applicable to any adult individual,
regardless of gender or ethnicity7,18.
MA and UA was the paired t-test (Table 3). A 95% Upon studying some well-respected cephalo-
confidence interval (CI) was used in this test. metric analyses, it was possible to identify fixed
As the p-value of the test was 0.094 > 0.05 maxillary relations that could be transferred to the
(>0.05), there was no statistically significant dif- mandible, thus establishing a maxillomandibular
ference between the UA and MA. relationship in the vertical plane by means of a
To validate the paired t-test, the distribution of correlation among the angles.
the difference between the variables should be Hence, according to the described methodology,
distributed normally. The UA and MA come from a it could be observed that a UA angle (Na, CF, ENA)
normal distribution (Fig. 7). was determined for the násio, facial centre and
To verify whether there was in fact a difference anterior nasal bone. Also, as described in the
between the measures of the angles regarding the Material and methods, the UA was transferred to
type of angle (upper and middle) and the gender the mandibular plane and renamed as the TLA. In

Table 2 Statistical values of the upper and middle angles

Standard Variation
Variable N Average Deviation Variance Minimum Maximum Q1 Median Q3 Coefficient

Upper Angle 31 50.29 3.35 11.23 45 57 48 50.5 53 6.66

Middle Angle 31 49.95 3.37 11.37 45 58 47.5 50 53 6.75

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6 K. T. Aguiar Tavano et al.
Table 4 ANOVA test values for the upper and middle angles as to male and female genders.
Source DF Seq SS
Angle 1 1.78
Gender 1 12.86
Error 59 665.20
Total 61 679.84
S = 3.35777 R2 = 2.15% R2 (adj) = 0.00%
Source: Research data.
addition, the upper edge of the TLA crossed the
lower edge of the UA, thus forming a third angle
called the MA.
The aesthetic analysis showed that in all of the
studied individuals, the UA was equal to the MA
and the MA was equal to the TLA. Therefore, it
could be concluded that the lower edge of the UA is
parallel to the mandibular plane (lower edge of the
TLA) and that the upper edge of the UA is parallel
to the upper edge of the TLA.
Based on the theorem of parallel straight lines,
described by Tales de Mileto, it is feasible to
establish the inverse path, that is, to determine the
UA and, parallel to its lower edge, design the
mandibular plane, because these appeared as par-
allel in all dentate adult cases. Therefore, it is pos-
sible in individuals who have lost or suffered
modifications in the height of the crowns of the
posterior teeth to reposition the mandible in such
a way that these aforementioned straight lines
remain parallel. This quality, in the final analysis,
determines the height of the lower third of the face,
because the parallelism between these straight
lines, when crossed by another, forms alternate
Figure 7 Normal distribution of
upper and middle angles.
Adjusted SS Adjusted MS F P
1.78 1.78 0.16 0.693
12.86 12.86 1.14 0.290
665.20 11.27
angles that are equal. Thus, the same UA value is
obtained.
The search for methods with statistical valida-
tion is imperative. Brzoza et al.14 affirm that
reference points found in the soft tissue are
unstable and cannot be defined. For this reason,
the use of bone references increases the accuracy
of these measurements. This quest is not new.
Ricketts19, McNamara17, Orthlieb, Laurent and
Laplanche1 and Brzoza et al. 14 have developed
and published works on techniques to determine
the VDO.
However, the analyses of this study are based
on average values that are predetermined and
that, although they present statistically significant
values, do not demonstrate the possibility of indi-
vidualisation. This finding is in accordance with
Orthlieb et al.1, who report that the correlations are
more interesting than the average values, espe-
cially as they are more specific for each patient.
Therefore, in the present study, the angles referent
to the upper and middle third of the face should
present a correlation with the angles determined
within the lower third of the face, regardless of the
 2011 The Gerodontology Society and John Wiley & Sons A/S

presence or absence of teeth. The same authors also
consider the relevance of establishing the appro-
priate lower portion of the face in patients who
require prosthetic treatment.
Concerning the importance of determining the
lower third of the face, our findings are in agree-
ment with Sheppard and Sheppard5, Çiftçi et al.4,
Miyasaki et al. 8 and Shimizu et al.7. These authors
affirm that the non-reestablishment of this height
significantly compromises function, aesthetic
function and, consequently, the stomatognathic
system, thus influencing the patients’ quality of
life. However, authors such as Bassi et al. 20,21
report that the use of cephalometric radiographs
and the analyses of these to establish the posi-
tioning of the posterior and anterior teeth, and
consequently the VDO, not the guarantee on an
easy determination of the facial height, owing to
the accentuated intraoral variability.
Many studies have been conducted to verify
changes in the gonial angles of edentulous patients.
Studies carried out on the panoramic radiographs
of young and adult dentate individuals and the
edentulous elderly sought to investigate the rela-
tionship of the size of the gonial angle with sex,
age, the cortical thickness of the angle, height of
mandibular residual body, and the period of
edentulism in the elderly. Huumonen et al. 22
concluded that the edentulous elderly had greater
gonial angle than dentate patients. The size of the
angle was correlated with the low height of the
residual mandibular body and cortical thickness in
edentulous women. Changes in mandibular mor-
phology as a result of loss of teeth can be expressed
as an increased gonial angle and shortening of the
ramus and condylar height. These results under-
score the importance of rehabilitation of the mas-
ticatory system to maintain proper functioning of
the masticatory muscles for the longest possible
time. Xie and Ainamo23 also found that the eden-
tulous elderly had more pronounced mandibular
angles, and this is correlated with a lower height of
mandibular residual body, which suggests that the
masticatory function of the natural dentition and
dentures can influence the change in the mandib-
ular angle. Serial panoramic radiographs of patients
who had their teeth extracted and dentures put in
were examined over a 3-year period.24 The value of
the gonial angle tended to increase on both sides of
the mandible after dental extractions. After the
third measure, conducted annually, the values
began to decline for both sides. The authors con-
cluded that after the use of dentures for 3 years, a
statistically significant decrease was found in the
gonial angle.
 2011 The Gerodontology Society and John Wiley & Sons A/S
Determination of vertical dimension of occlusion 7
These studies demonstrate that there is a change
in gonial angle in edentulous patients, but there is
still much controversy in the literature about it.
The construction technique for this study requires
the inclusion of the gonial angle, but not its
application. This means that to apply the technique
described in this study in dentate patients or in
edentulous individuals who lost their occlusal
vertical dimension, it is not necessary to use the
gonial angle but rather the mandibular plane to
position the jaw in the correct position. Further-
more, the increase in this angle is already seen in
the first radiograph taken to perform cephalometric
tracing and analysis, so it is incorporated and does
not have to be changed during the time in which
the dentures are being made. If the gonial angle is
increased, when completing the reverse path, there
would be no difference, because what we want is to
get the correct positioning of the mandible using
the mandibular plane in relation to the maxilla,
because what guided us is the difference found
between the initial mandibular plane, considered
‘wrong’, and the new plane obtained by cephalo-
metric analysis through the transposition of the
parallel line to the plane between the CF–ENA. This
difference, which is seen in the mentum region, is
what will be incorporated into the anterior teeth of
a future denture to ensure that this parallelism
occurs, is seen in a new radiograph, and that the
vertical dimension of the occlusion is restored.
The validity of the Seraidarian-Tavano cephalo-
metric analysis was verified in this study to deter-
mine the lower facial height in adult, dentate
patients, without occlusal interferences, based on the
premise that the VDO of these is natural and correct
and that this facial height, upon being studied with
this cephalometric analysis, will also be natural and
correct. The present study was aimed at guaran-
teeing that the angles formed within this analysis
were not dependent on the teeth so that these
could also be used in determining the VDO in
patients who were partially or totally toothed, or
with some alteration in this height parameter.
As described by a number of authors4,13,25–27,
cephalometric analyses can facilitate or determine
lower facial height, thus aiding in the construction
of full prostheses, partial prostheses and prostheses
for those in extensive prosthetic rehabilitation. In
this manner, the present study attempted to
discover a technique that would allow for the
factors mentioned in this study as well as the use of
this analysis by professionals in the areas of
orthodontics and orthopaedics. The objective was
to determine whether the initial VDO was
presented correctly or not and, after the ortho-
8 K. T. Aguiar Tavano et al.
dontic movement or surgery, verify the conclusion
of cases that refer to these lower facial heights in
their recommendations for correct positioning.
As this research presents a methodology to
determine the VDO by means of the cephalometric
analysis, its comparison with other already
accepted cephalometric methods becomes impos-
sible. However, certain pre-established measures
from other authors were used and compared in an
attempt to prove the efficacy of the Seraidarian-
Tavano method.
It should be noted that the number of images
used in this work was still numerically insufficient.
Nevertheless, the statistical result proved to be
quite positive and therefore calls for further
research regarding this same methodology in
specific countries, with the ultimate aim of con-
tributing to the improvement in a highly relevant
measuring system for dentistry.
Conclusions
This study was able to develop methodology called
Seraidarian-Tavano to determine the VDO by means
of a lateral cephalometric analysis. This new
cephalometric methodology was developed using
bone structures and can be applied regardless of the
presence or absence, full or in part, of teeth. It is
hoped that other authors will apply this method-
ology in clinical studies, with the objective of
solidifying and improving the methodology.
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 2011 The Gerodontology Society and John Wiley & Sons A/S