Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2015 42; 875–882
Review
Does altering the occlusal vertical dimension produce
temporomandibular disorders? A literature review
I. MORENO-HAY & J. P. OKESON Orofacial Pain Center, College of Dentistry, University of Kentucky, Lexington,
KY, USA
SUMMARY The purpose of this review was to
present a comprehensive review of the scientific
evidence available in the literature regarding the
effect of altering the occlusal vertical dimens-
ion (OVD) on producing temporomandibular
disorders. The authors conducted a PubMed search
with the following search terms ‘temporoman-
dibular disorders’, ‘occlusal vertical dimension’,
‘stomatognatic system’, ‘masticatory muscles’ and
‘skeletal muscle’. Bibliographies of all retrieved
articles were consulted for additional publications.
Hand-searched publications from 1938 were
included. The literature review revealed a lack of
well-designed studies. Traditional beliefs have
been based on case reports and anecdotal opinions
rather than on well-controlled clinical trials. The
available evidence is weak and seems to indicate
Introduction
Traditionally, it has been believed that changing
the occlusal vertical dimension (OVD) is a precari-
ous dental procedure causing problems such as
muscle pain, temporomandibular joint pain, head-
aches, tooth grinding and clenching. In the first
decades of the last century, some authors expressed
their concerns about the ‘dangers’ of altering the
OVD (1, 2). They hypothesised that changing the
OVD caused physical suffering due to muscle strain
(1). These authors believed that shortening of the
lower third of facial (a decrease in the OVD) was a
product of natural adaptation. Therefore, restoring
this vertical dimension (e.g. edentulous patients)
was an extreme dental treatment that went against
© 2015 John Wiley & Sons Ltd
that the stomatognathic system has the ability to
adapt rapidly to moderate changes in occlusal
vertical dimension (OVD). Nevertheless, it should
be taken into consideration that in some patients
mild transient symptoms may occur, but they are
most often self-limiting and without major
consequence. In conclusion, there is no indication
that permanent alteration in the OVD will
produce long-lasting TMD symptoms. However,
additional studies are needed.
KEYWORDS: vertical dimension, temporomandibular
joint disorders, dental occlusion, stomatogna-
thic system, masticatory muscles and prosthetic
dentistry
Accepted for publication 31 May 2015
the delicate balance of the stomatognathic system
(1, 2).
Additionally, some decades later, several authors
reported that creating an inadequate OVD by either
increasing or decreasing it could create serious prob-
lems (3–5). They believed the OVD was a specific and
fixed value that cannot be changed and that this
value should be carefully and accurately calculated so
that it will not be altered when treating patients.
Despite the fact that these conclusions were based
solely on opinions and/or case reports, these beliefs
have remained throughout the decades. It has since
been believed that altering the OVD leads to the
development of signs and symptoms of temporoman-
dibular disorders (TMD). According to the Guide-
lines of the American Academy of Orofacial Pain,
doi: 10.1111/joor.12326
876 I. MORENO-HAY & J. P. OKESON
temporomandibular disorders (TMD) are defined as
‘a collective term embracing a number of clinical
problems involving the temporomandibular joint
(TMJ), masticatory muscles or both’ (6).
More recently, attention has been drawn towards
changing OVD (7). This article will review the litera-
ture regarding the effect of altering the OVD on pro-
ducing TMD symptoms. The authors conducted a
comprehensive search through PubMed from 1966 to
2013 with the following search MeSH (medical sub-
ject heading) terms ‘temporomandibular disorders’,
‘occlusal vertical dimension’, ‘stomatognatic system’,
‘masticatory muscles’ and ‘skeletal muscle’. Filters for
English language were applied. A total of 380 were
initially identified. After reading the abstracts, only 71
papers were selected. After full-text analysis, 6 papers
were excluded as not having information related to
this subject review. Bibliographies of all retrieved arti-
cles were consulted for additional publications, and 2
additional articles were disclosed. Hand-searched pub-
lications from 1938 were included. A total of 67
papers met the purpose of the study. These papers
were reviewed, and both authors concluded that
there were no randomised clinical trials available. The
articles were often scientifically flawed because of
design flaws, small study populations, lack of controls
and others. Furthermore, most of the conclusions
were based in case reports and opinions rather than
in well-controlled clinical trials. This article will
review the past and present views, and the authors
will compare the clinical opinions on this topic and
the outcomes reported in the available literature.
Available evidence will be presented to answer the
following questions: Does increasing OVD lead to
TMD?; Does decreasing OVD lead to TMD?; and Can
the stomatognathic system adapt to changes in OVD?
Does increasing OVD lead to TMD?
One of the early studies that investigated OVD was
written by Christensen in 1970 (8). He increased the
OVD in 20 healthy dentate patients and 22 complete
denture patients by placing overlays on the mandib-
ular molars for a period of 3–7 days. He reported
that subjects developed several symptoms after
increasing the OVD, but these symptoms were of
mild intensity and more frequent in the group of
dentate subjects compared to complete denture
patients. The symptoms were initiated as early as
one hour after the overlays were inserted and lasted
on average 30 h. Clenching and grinding of teeth
appeared in the first 36 h after insertion in both
groups and disappeared before the experiment had
ended. He concluded that increasing the OVD
resulted in an increased masticatory muscle and joint
pain.
Although this was one of the first studies to evalu-
ate symptoms associated with an increase of vertical
dimension, there were some confounding factors that
need to be considered. Certainly increasing the
height of the molars altered the vertical dimension;
however, with this increase in OVD there may have
also been a loss of occlusal stability. Therefore, the
symptomatology reported may have been the results
of the occlusal instability and not the increase in
OVD (9–12).
In a later study, Carlsson et al. (13) investigated
the effect of increasing vertical dimension (3
9 mm)
by means of posterior acrylic appliances which pro-
vided good occlusal stability in 6 healthy patients
with no TMD signs or symptoms maintained for
7 days. The results demonstrated that subjects pre-
sented with moderate subjective symptoms, which
decreased after 1–2 days. The main complaints were
discomfort in wearing the splints, speech difficulties
and cheek biting. The clinical examination performed
did not demonstrate pain upon palpation any masti-
catory muscles or the TMJ structures. Thus, the
authors concluded that increasing OVD did not seem
to be a hazardous procedure when good occlusal sta-
bility was achieved.
In an another study, Dahl et al. (14) evaluated the
effect of increasing the vertical dimension (range:
1
8–4
7 mm) by placing a partial chrome-cobalt splint
covering the maxillary anterior teeth for 6–14 months
in 20 patients with severe tooth attrition. The use of a
partial splint led to the intrusion of the anterior seg-
ment and extrusion of posterior teeth. Regarding the
development of TMD signs and symptoms, the study
reported that the splint caused short and transient dis-
comfort, concluding that the increase of vertical
dimension is well tolerated in most cases. This same
sample was followed for a period of 5
5 years after
anterior teeth were restored with crowns at the new
vertical dimension, and no TMD symptoms were evi-
dent (15). This indicated that patients adapted to
changes in their OVD in a relatively short period of
time.
© 2015 John Wiley & Sons Ltd
 OCCLUSAL VERTICAL DIMENSION AND TEMPOROMANDIBULAR DISORDERS
Another study was performed evaluating the effect
of the abovementioned ‘Dahl’-type appliances. The
sample consisted of 45 patients who received different
appliances for a mean of 5
9 months and were fol-
lowed up to 4
43 years. They indicated that 94% of
the sample reported no discomfort during splint treat-
ment, 2% complained about mild muscular discom-
fort and 4% complained about moderate dysfunction,
that subsided before the end of the treatment (16).
In a study by Gross et al. (17), OVD was increased
by means of a complete arch acrylic fixed dentures
(3
5–4
5 mm interincisally) in 8 healthy subjects with
severe dental wear. The study reported initial speech
difficulties and muscle discomfort that subsided after
1–2 weeks. The authors demonstrated that a new
interocclusal rest space was re-established after incre-
asing the OVD and this remained stable at the 2-year
follow-up (18).
The same authors analysed the differences in
increasing OVD in a range between 3 and 5 mm with
fixed prosthesis on natural dentition and implant-
supported restorations in 30 patients, followed for a
period of 66 months. They reported that all the
patients adapted to the new OVD. Only 6 patients in
the implant-supported group developed tooth clench-
ing or grinding that subsided after 2–3 months (19).
In another study, Tryde et al. (20) concluded that
patients adapt to increases in OVD. They calculated
that the ‘comfortable zone’ varied on average about
1
3 mm with the increased OVD.
Hellsing in 1987 studied the adaptability in edentu-
lous patients when altering the OVD. He demon-
strated that patients adapt very quickly to a new
vertical dimension, creating a new interocclusal space
of 3
3 mm (21).
It should be noted that the studies that investigated
the relationship between increasing OVD and TMD
symptoms were all conducted on relatively small
changes in OVD, likely within the freeway space. Lar-
ger changes in OVD have not been well studied.
In summary, a review of the available literature
regarding the effect of increasing OVD is limited. The
scientific merit of the available studies is compromised
by the lack of adequate sample size, control groups,
randomisation and, in most of the cases, long-term
follow-up. However, in spite of these shortcomings,
the results of these studies do not suggest that
increasing the OVD leads to the development, aggra-
vation or perpetuation of TMD symptoms. On the
© 2015 John Wiley & Sons Ltd
877
contrary, the few published studies show a trend
demonstrating that mild transient TMD symptoms
may appear after moderate increases of OVD and
these symptoms routinely resolve rather quickly.
These findings suggest that the stomatognathic system
has great ability to adapt to increases in OVD (22–25)
without any major clinical consequences.
Does decreasing OVD lead to TMD?
Similar to increasing the OVD, there are conflicting
reports in the literature regarding the effects of
decreasing the OVD. Some authors have suggested
that the stomatognathic system naturally adapts to
decreases in OVD, for example in cases of tooth loss
or severe dental attrition (1, 2). Conversely, other
authors have suggested that a decrease in OVD can
predispose the patient to TMD (3, 4). Nevertheless,
there is no strong evidence in the literature support-
ing either of these statements.
It has been reported that severely worn dentitions
resulting in a decrease in OVD are usually due to
parafunctional habits or an abrasive diet (26). How-
ever, patients with significant tooth wear do not regu-
larly present signs or symptoms of TMD (15).
Interestingly, Pullinger et al. (27) studied the corre-
lation between the presence of severe dental attrition
and TMD. They did not find any statistically signifi-
cant correlation between the degree of dental attrition
and TMD symptoms. Nevertheless, the same authors
repeated the study in 2006 (28) and published that
the presence of dental attrition could differentiate
patients with masticatory muscle pain from controls
and patients with intracapsular disorders. It is impor-
tant to note that the cause of the masticatory muscle
disorder was not determined to be associated with the
loss of OVD. Perhaps a more logical association may
be the increased use of the masticatory muscles in
patients with severe dental attrition.
There is also controversy in the literature regarding
the relationship between the loss of natural dentition
and TMD (29). Pullinger and Seligman (12) published
that TMD risk factors included the following: anterior
open bite, cross-bite, overjet more than 6 mm, dis-
crepancy between centric relation and intercuspal
position more than 2 mm and loss of posterior teeth
(9, 30). As abovementioned, the loss of posterior teeth
often results in occlusal instability that is considered
as a possible aggravating, perpetuating or predisposing
878 I. MORENO-HAY & J. P. OKESON
factor for TMD (31). However, it has been shown that
even in shortened arches, good occlusal stability can
be obtained (32). On occasion, the mandible may pro-
trude to obtain major stability resulting in an overload
of the anterior teeth (23) and possibly overloading
the TMJ. However, this has not been demonstrated to
routinely decrease OVD.
It has been suggested that an increase in signs and
symptoms of TMD in elderly populations may be due
to loss of the natural dentition and use of complete
dentures (33). However, Schmitter (34) demonstrated
that in the geriatric population (68–96 years old)
symptoms of TMD actually decrease, whereas signs
such as TMJ sounds increase in the elderly. An early
assumption made by Tench in 1938 suggested a natu-
ral adaptability of the stomatognathic system with age
(1).
It is interesting to note that when complete den-
tures are placed patients immediately adapt to a wide
range of variation in OVD which is a different OVD
from not having the dentures in place (4). This seems
to once again demonstrate the adaptability of the
masticatory system.
To summarise, a review of the available literature
regarding the effect of decreasing OVD on producing
TMD is very limited. There are no well-controlled
studies, and most opinions are drawn from observa-
tions associated with loss of tooth structure. A
decrease in OVD may occur with the loss of posterior
teeth but, because other risk factors such as occlusal
instability are involved, the relationship between
decreased in OVD and TMD cannot be determined. It
is logical to assume that a severely worn dentition
results in a decrease in OVD. However, evidence does
not suggest that there is increased presence of TMD
symptoms in severely worn dentition. Perhaps this is
further evidence of the favourable adaptability of the
stomatognathic system.
How does the stomatognathic system
adapt to changes in OVD?
The studies reviewed in the above sections lead to the
conclusion that the stomatognathic system has the
ability to adapt to changes in the OVD. Although in
some studies, rapid changes in OVD in healthy indi-
viduals seem to lead to mild TMD symptoms, these
symptoms seem to resolve relatively quickly. The fol-
lowing section will discuss how altering the OVD can
impact on the different structures of the masticatory
system including muscles and TMJs. The effect of
altering OVD on the dentition (35) is not in the scope
of this study.
Traditionally, it was suggested that increasing OVD
led to muscle strain resulting in muscle hyperactivity,
which predisposes to muscle pain (2, 3). Conversely,
EMG studies have demonstrated the opposite. Manns
et al. (36) demonstrated that the resting EMG activity
of the masseter muscle was minimum at an interme-
diate range of mouth opening that varied between 10
and 16 mm of mouth opening depending on the mus-
cle studied. Once the above-named range of mouth
opening was reached, the EMG activity increased as
maximum opening was obtained (37).
Thus, the so-called rest position is an active muscu-
lar position where masticatory muscles present a con-
stant muscle activity positioning the jaw against the
forces of gravity. Rugh et al. (38) demonstrated that
there was a difference of 6 mm between this position
and the minimal EMG, proposing the term of postural
position of the jaw instead of rest position.
Additionally, Gross et al. (39) demonstrated that
there was not a minimum EMG point during mouth
opening. A mean plateau of EMG activity was found
from maximal intercuspation to 20 mm of mouth
opening, suggesting that masticatory muscles present
a minimum EMG activity at a range of mouth open-
ing and not at a specific fixed position. Using this
same logic, regarding the EMG activity, interocclusal
rest space could also be better described as that of a
range instead of a fixed position (36, 40, 41).
In contrast, maximum bite force is achieved at the
range of 15–20 mm of mouth opening and its mini-
mum is found at maximum opening (36). It has been
shown that bite force is decreased in patients with
worn dentition but progressively increases 8–12 weeks
after the daily use (8–10 h) of a stabilisation appliance.
These same results are achieved in a control group
(42).
Moreover, when muscles are relaxed, for example
under hypnosis, 43–50% reduction of EMG activity
was observed in masseter and temporalis muscles
when the interocclusal space was increased from 2
2
to 8
9 mm (43).
It has been proposed that one possible mechanism
of action of occlusal appliances is related to increasing
the vertical dimension (31). In patients with TMD,
the interocclusal appliance (IOA) adjusted at the OVD
© 2015 John Wiley & Sons Ltd
 OCCLUSAL VERTICAL DIMENSION AND TEMPOROMANDIBULAR DISORDERS
corresponding to the minimum EMG activity was
more effective in reducing symptomatology. Reduc-
tion in TMD symptoms was also faster for those
patients wearing IOA at an increased OVD of 8
15 or
4
42 mm than an IOA increased at 1 mm (44, 45).
Several studies have demonstrated that the EMG
activity of masticatory muscles at postural position
decreases when the IOA is used (46, 47).
It is noteworthy that there is no conclusive evi-
dence regarding the association between pain and
increased levels of EMG activity (48, 49). Therefore,
the clinical relevance of increased EMG activity of the
masticatory and cervical muscles remains unclear
(49).
In animal models, several studies have demon-
strated that plastic changes in muscle fibres occur fol-
lowing increases in OVD. In short-term studies, after
2 weeks of increased OVD, it was found that there
was an increase in type II a fibres (slower phenotype)
in the deep masseter muscle of open bite mice com-
pared to the increase of type II b fibres (faster pheno-
type) of controls (50, 51). Conversely, another study
demonstrated that no histochemical differences were
found after 4 weeks in open bite rats (52).
These findings suggest that there is a great degree
of adaptability in masticatory muscles following
changes in OVD. Even though initial differences can
be found in the phenotype of muscle fibres, they sub-
sided after 4 weeks (53, 54).
Mechanistic finite element models have been
recently developed to study the sarcomerogenesis
response of adult skeletal muscles to passive over-
stretch (55, 56). It has been reported that the opti-
mum length of the skeletal muscle regulates the
number of sarcomeres. Thus, when the muscle is held
at a shortened length, the number of sarcomere units
decrease (57). This dynamic phenomenon is well
described in the literature as muscle plasticity (58, 59)
and has been studied in surgical limb lengthening and
tendon transfer surgeries (60–66).
Similarly, after orthognathic surgery, differences in
muscle size have been observed in long-term studies.
It has been shown that muscles adapted to the new
craniofacial morphology. After an initial increase in
thickness was noted, at 4 years post-surgery the thick-
ness was no longer noticeable (67).
Muscle size has also been studied by Kiliaridis et al.
(68) in children with class II malocclusion treated
with functional appliances for 9–17 months that
© 2015 John Wiley & Sons Ltd
879
resulted in an increase of vertical dimension of
5
2 mm. They demonstrated by means of ultrasono-
graphic examination that increase of OVD lead to
mild atrophy of the masseter muscle compared to
controls.
Increasing OVD may also alter TMJ condylar posi-
tion. Hellsing et al. (69) using radiographic examina-
tion demonstrated that at an interincisal mouth
opening of 4–7 mm, there was not only pure rotation
of the condyles but also a degree of translation. How-
ever, the direction of the movement was random.
Thus, another possible mechanism of action of IOA
would be a change in condylar position related to the
increased OVD. Perhaps this may even reduce the
load of the TMJ. Nitzan et al. 1994 (70) studied TMJ
intra-articular pressure with different mouth openings
as well as with and without an IOA. She demon-
strated that during maximal mouth opening, the
intra-articular pressure was negative, whereas during
maximal voluntary clenching, the pressure was posi-
tive. Furthermore, when an IOA was placed and the
patient was asked to clench, the intra-articular pres-
sure was reduced in 81%. Given the anatomic reali-
ties of the TMJ being loaded at all times, these results
are not likely valid and have not been reproduced.
It is interesting to note that Manns et al. (44) dem-
onstrated that an increase in OVD in patients with
muscle TMD reduced the painful symptoms. These
findings suggest that a change in the working length
of a painful muscle may actually reduce painful symp-
toms. This is certainly clinically verified when muscles
that are tight and painful are passively stretched or
lengthened. This, however, does not suggest that if
this particular length is maintained, it will keep the
patient muscle pain free indefinitely. This concept is
not well appreciated in dentistry. In fact, when a
patient reports a reduction in pain with an increased
OVD, the dentist often assumes that this is the correct
vertical dimension and if it were permanently estab-
lished, the patient would be permanently free of pain.
This concept is not evidence based but is still common
in the practice of dentistry. In fact, muscles seem to
be more pain free when they are allowed to change
their length during normal function.
This section can be summarised by stating that the
evidence does suggest that the stomatognathic system
can adapt and does so routinely when OVD is altered,
ether naturally or by dental procedures. Adaptation
may be the results of muscle or joint responses, or
880 I. MORENO-HAY & J. P. OKESON
both. Further studies are needed to more completely
understand this process of adaptation.
Conclusion
This literature review revealed a lack of well-
designed studies investigating the relationship
between altering the OVD and producing TMD.
Although some clinicians believe that changes in
OVD are closely related to TMD symptoms, there is
little evidence that this relationship exists. Traditional
beliefs about this relationship have been based on
case reports and anecdotal opinions rather than on
well-controlled clinical trials. The evidence available
to the date indicates that the stomatognathic system
has the ability to adapt rapidly to moderate changes
in OVD (<5 mm).
Nevertheless, it should be taken into consideration
that in some patients, mild transient symptoms of
TMD may occur, but they are most often self-limiting
and without major consequence. On the other hand,
in some instances, clinicians may increase the OVD
with an oral splint as a treatment for TMD symptoms.
This strategy usually produces symptomatic relief, and
most patients’ muscles appear to adapt well to this
approach. However, some clinicians have interpreted
this outcome as an indication for permanently raising
the vertical dimension, but that is not an appropriate
conclusion. Instead, the IOA should gradually be
removed after the symptoms get better.
As the available evidence is weak and does not
allow any solid clinical recommendation, when there
are therapeutic needs to increase the OVD (i.e. pros-
thodontic needs, aesthetics and function) care should
be taken to incorporate minimum changes and that
orthopaedic stability is maintained during such
change. Changes in OVD may be assisted by utilising
an IOA or temporary crowns that can be fabricated at
the increased OVD. The patient should be observed
for an adequate period of time to assure a positive
stomatognathic response. Permanent occlusal changes
should only be attempted after the patient has dem-
onstrated adaptability at the new vertical dimension.
In conclusion, much of the concepts regarding OVD
and TMD are unfounded by scientific evidence. Addi-
tional studies are needed to more completely under-
stand this relationship as well as important factors
that may need to be considered when there are clini-
cal needs to change a patient’s OVD.
Disclosure/Acknowledgment
Drs. Moreno-Hay and Okeson have no disclosures or
no competing financial interests. No conflict of inter-
est was declared. This research was carried out with-
out funding.
References
1. Tench R. Dangers in dental reconstruction involving
increase of the vertical dimension of the lower third of the
human face. J Am Dent Assoc. 1938;26:566–570.
2. Schuyler C. Problems associated with opening the bite
which would contraindicate it as a common procedure. J
Am Dent Assoc. 1939;26:734–740.
3. Monteith B. The role of the free-way space in the genera-
tion of muscle pain among denture-wearers. J Oral Rehabil.
1984;11:483–498.
4. Gattozzi JG, Nicol BR, Somes GW, Ellinger CW. Variations
in mandibular rest positions with and without dentures in
place. J Prosthet Dent. 1976;36:159–163.
5. Koka S. Vertical dimension of occlusion. Int J Prosthodont.
2007;20:342.
6. De Leeuw RKG. Orofacial pain: guidelines for assessment,
diagnosis and management, 5th ed. Hannover Park (IL):
International Quintenssence Publishing Co.; 2013.
7. Moreno-Hay IOJ. Dysfonctionement de l’appareil manduca-
teur et dimension verticale d’occlusion: revue de la littera-
ture. Realites Cliniques. 2013;24:93–158.
8. Christensen J. Effect of occlusion-raising procedures on the
chewing system. Dental Pract Dent Rec. 1970;20:233–238.
9. Harper GW, Stewart CJ. Treatment and management of
temporomandibular joint dysfunction (TMJ) with a modified
removable partial denture. W V Dent J. 1993;67:10–12.
10. De Boever JA, Carlsson GE, Klineberg IJ. Need for occlusal
therapy and prosthodontic treatment in the management of
temporomandibular disorders. Part II: tooth loss and prosth-
odontic treatment. J Oral Rehabil. 2000;27:647–659.
11. De Boever JA, Carlsson GE, Klineberg IJ. Need for occlusal
therapy and prosthodontic treatment in the management of
temporomandibular disorders. Part I. Occlusal interferences
and occlusal adjustment. J Oral Rehabil. 2000;27:367–379.
12. Pullinger AG, Seligman DA, Gornbein JA. A multiple logistic
regression analysis of the risk and relative odds of temporo-
mandibular disorders as a function of common occlusal fea-
tures. J Dent Res. 1993;72:968–979.
13. Carlsson GE, Ingervall B, Kocak G. Effect of increasing verti-
cal dimension on the masticatory system in subjects with
natural teeth. J Prosthet Dent. 1979;41:284–289.
14. Dahl BL, Krogstad O. The effect of a partial bite raising
splint on the occlusal face height. An x-ray cephalometric
study in human adults. Acta Odontol Scand. 1982;40:17–24.
15. Dahl BL, Krogstad O. Long-term observations of an
increased occlusal face height obtained by a combined
orthodontic/prosthetic approach. J Oral Rehabil. 1985;12:
173–176.
© 2015 John Wiley & Sons Ltd
 OCCLUSAL VERTICAL DIMENSION AND TEMPOROMANDIBULAR DISORDERS
16. Gough MB, Setchell DJ. A retrospective study of 50 treat-
ments using an appliance to produce localised occlusal space
by relative axial tooth movement. Br Dent J. 1999;187:
134–139.
17. Gross MD, Ormianer Z. A preliminary study on the effect of
occlusal vertical dimension increase on mandibular postural
rest position. Int J Prosthodont. 1994;7:216–226.
18. Ormianer Z, Gross M. A 2-year follow-up of mandibular
posture following an increase in occlusal vertical dimension
beyond the clinical rest position with fixed restorations.
J Oral Rehabil. 1998;25:877–883.
19. Ormianer Z, Palty A. Altered vertical dimension of occlu-
sion: a comparative retrospective pilot study of tooth- and
implant-supported restorations. Int J Oral Maxillofac
Implants. 2009;24:497–501.
20. Tryde G, Stoltze K, Morimoto T, Salk D. Long-term changes
in the perception of comfortable mandibular occlusal posi-
tions. J Oral Rehabil. 1977;4:9–15.
21. Hellsing G, Ekstrand K. Ability of edentulous human beings
to adapt to changes in vertical dimension. J Oral Rehabil.
1987;14:379–383.
22. Abduo J. Safety of increasing vertical dimension of occlu-
sion: a systematic review. Quintessence Int. 2012;43:369–
380.
23. Abduo J, Lyons K. Clinical considerations for increasing
occlusal vertical dimension: a review. Aust Dent J.
2012;57:2–10.
24. Mack MR. Vertical dimension: a dynamic concept based on
facial form and oropharyngeal function. J Prosthet Dent.
1991;66:478–485.
25. Hellsing G. Functional adaptation to changes in vertical
dimension. J Prosthet Dent. 1984;52:867–870.
26. Rivera-Morales WC, Mohl ND. Restoration of the vertical
dimension of occlusion in the severely worn dentition. Dent
Clin North Am. 1992;36:651–664.
27. Pullinger AG, Seligman DA. The degree to which attrition
characterizes differentiated patient groups of temporoman-
dibular disorders. J Orofac Pain. 1993;7:196–208.
28. Seligman DA, Pullinger AG. Dental attrition models predict-
ing temporomandibular joint disease or masticatory muscle
pain versus asymptomatic controls. J Oral Rehabil.
2006;33:789–799.
29. Yannikakis S, Zissis A, Harrison A. The prevalence of tempo-
romandibular disorders among two different denture-
wearing populations. Eur J Prosthodont Restor Dent. 2009;
17:35–40.
30. Wang MQ, Xue F, He JJ, Chen JH, Chen CS, Raustia A.
Missing posterior teeth and risk of temporomandibular dis-
orders. J Dent Res. 2009;88:942–945.
31. Okeson JP. Management of tempromandibular disorders and
occlusion, 7th ed. St. Louis (MO): Mosby/Elsevier; 2013.
32. Witter DJ, Creugers NH, Kreulen CM, de Haan AF. Occlusal
stability in shortened dental arches. J Dent Res.
2001;80:432–436.
33. Rutkiewicz T, Kononen M, Suominen-Taipale L, Nordblad A,
Alanen P. Occurrence of clinical signs of temporomandibular
disorders in adult Finns. J Orofac Pain. 2006;20:208–217.
© 2015 John Wiley & Sons Ltd
881
34. Schmitter M, Rammelsberg P, Hassel A. The prevalence of
signs and symptoms of temporomandibular disorders in very
old subjects. J Oral Rehabil. 2005;32:467–473.
35. Beyron HL. Characteristics of functionally optimal occlusion
and principles of occlusal rehabilitation. J Am Dent Assoc.
1954;48:648–656.
36. Manns A, Miralles R, Guerrero F. The changes in electrical
activity of the postural muscles of the mandible upon vary-
ing the vertical dimension. J Prosthet Dent. 1981;45:
438–445.
37. Manns A, Miralles R, Palazzi C. EMG, bite force, and elon-
gation of the masseter muscle under isometric voluntary
contractions and variations of vertical dimension. J Prosthet
Dent. 1979;42:674–682.
38. Rugh JD, Drago CJ. Vertical dimension: a study of clinical
rest position and jaw muscle activity. J Prosthet Dent.
1981;45:670–675.
39. Gross MD, Ormianer Z, Moshe K, Gazit E. Integrated elec-
tromyography of the masseter on incremental opening and
closing with audio biofeedback: a study on mandibular pos-
ture. Int J Prosthodont. 1999;12:419–425.
40. Burnett CA, Clifford TJ. A preliminary investigation into the
effect of increased occlusal vertical dimension on mandibu-
lar movement during speech. J Dent. 1992;20:221–224.
41. Garnick JRSP. Rest position. An electromyographic and clin-
ical investigation. J Prosthet Dent. 1962;12:895.
42. Jain V, Mathur VP, Abhishek K, Kothari M. Effect of occlu-
sal splint therapy on maximum bite force in individuals
with moderate to severe attrition of teeth. J Prosthodont
Res. 2012;56:287–292.
43. Manns A, Zuazola RV, Sirhan RM, Quiroz M, Rocabado M.
Relationship between the tonic elevator mandibular activity
and the vertical dimension during the states of vigilance
and hypnosis. Cranio. 1990;8:163–170.
44. Manns A, Miralles R, Santander H, Valdivia J. Influence of
the vertical dimension in the treatment of myofascial pain-
dysfunction syndrome. J Prosthet Dent. 1983;50:700–709.
45. Manns A, Miralles R, Cumsille F. Influence of vertical
dimension on masseter muscle electromyographic activity in
patients with mandibular dysfunction. J Prosthet Dent.
1985;53:243–247.
46. Kovaleski WC, De Boever J. Influence of occlusal splints on
jaw postion and musculature in patients with temporoman-
dibular joint dysfunction. J Prosthet Dent. 1975;33:321–327.
47. Carr AB, Christensen LV, Donegan SJ, Ziebert GJ. Postural
contractile activities of human jaw muscles following use of
an occlusal splint. J Oral Rehabil. 1991;18:185–191.
48. Suvinen TI, Kemppainen P. Review of clinical EMG studies
related to muscle and occlusal factors in healthy and TMD
subjects. J Oral Rehabil. 2007;34:631–644.
49. Svensson P, Graven-Nielsen T. Craniofacial muscle pain:
review of mechanisms and clinical manifestations. J Orofac
Pain. 2001;15:117–145.
50. Widmer C, Nguyen VD, Chiang H, Morris-Wiman J.
Increased vertical dimension effects on masseter muscle
fiber phenotype during maturation. Angle Orthod. 2013;
83:57–62.
882 I. MORENO-HAY & J. P. OKESON
51. Ohnuki Y, Kawai N, Tanaka E, Langenbach GE, Tanne K,
Saeki Y. Effects of increased occlusal vertical dimension on
daily activity and myosin heavy chain composition in rat
jaw muscle. Arch Oral Biol. 2009;54:783–789.
52. Yaffe A, Tal M, Ehrlich J. Effect of occlusal bite-raising splint
on electromyogram, motor unit histochemistry and myoneu-
ronal dimensions in rats. J Oral Rehabil. 1991;18:343–351.
53. Yabushita T, Zeredo JL, Toda K, Soma K. Role of occlusal
vertical dimension in spindle function. J Dent Res.
2005;84:245–249.
54. Yabushita T, Zeredo JL, Fujita K, Toda K, Soma K. Func-
tional adaptability of jaw-muscle spindles after bite-raising.
J Dent Res. 2006;85:849–853.
55. Zollner AM, Abilez OJ, Bol M, Kuhl E. Stretching skeletal
muscle: chronic muscle lengthening through sarcomerogen-
esis. PLoS ONE. 2012;7:e45661.
56. Goldspink G, Williams P, Simpson H. Gene expression in
response to muscle stretch. Clin Orthop Relat Res. 2002;
October(403 Suppl):S146–S152.
57. Herring SW, Grimm AF, Grimm BR. Regulation of sarco-
mere number in skeletal muscle: a comparison of hypothe-
ses. Muscle Nerve. 1984;7:161–173.
58. Williams PE, Goldspink G. Changes in sarcomere length and
physiological properties in immobilized muscle. J Anat.
1978;127(Pt 3):459–468.
59. Goldspink G. Cellular and molecular aspects of muscle growth,
adaptation and ageing. Gerodontology. 1998;15:35–43.
60. Hayatsu K, De Deyne PG. Muscle adaptation during distrac-
tion osteogenesis in skeletally immature and mature rabbits.
J Orthop Res. 2001;19:897–905.
61. Zumstein MA, Frey E, von Rechenberg B, Frigg R, Gerber
C, Meyer DC. Device for lengthening of a musculotendinous
unit by direct continuous traction in the sheep. BMC Vet
Res. 2012;8:50.
62. Caiozzo VJ, Utkan A, Chou R, Khalafi A, Chandra H, Baker
M et al. Effects of distraction on muscle length: mechanisms
involved in sarcomerogenesis. Clin Orthop Relat Res. 2002;
October(403 Suppl):S133–S145.
63. Green SA, Horton E, Baker M, Utkan A, Caiozzo V. Distrac-
tion of skeletal muscle: evolution of a rat model. Clin Ort-
hop Relat Res. 2002;October(403 Suppl):S126–S132.
64. Williams P, Simpson H, Kyberd P, Kenwright J, Goldspink
G. Effect of rate of distraction on loss of range of joint
movement, muscle stiffness, and intramuscular connective
tissue content during surgical limb-lengthening: a study in
the rabbit. Anat Rec. 1999;255:78–83.
65. Friden J, Lieber RL. Tendon transfer surgery: clinical impli-
cations of experimental studies. Clin Orthop Relat Res.
2002;October(403 Suppl):S163–S170.
66. Matano T, Tamai K, Kurokawa T. Adaptation of skeletal
muscle in limb lengthening: a light diffraction study on the
sarcomere length in situ. J Orthop Res. 1994;12:193–196.
67. Lee DH, Yu HS. Masseter muscle changes following ortho-
gnathic surgery: a long-term three-dimensional computed
tomography follow-up. Angle Orthod. 2012;82:792–798.
68. Kiliaridis S, Mills CM, Antonarakis GS. Masseter muscle
thickness as a predictive variable in treatment outcome of
the twin-block appliance and masseteric thickness changes
during treatment. Orthod Craniofac Res. 2010;13:203–213.
69. Hellsing E, Hellsing G. Increase of vertical dimension–conse-
quences for the maxillomandibular relationship. A clinical
approach. J Oral Rehabil. 1995;22:243–247.
70. Nitzan DW. Intraarticular pressure in the functioning
human temporomandibular joint and its alteration by uni-
form elevation of the occlusal plane. J Oral Maxillofac Surg.
1994;52:671–679; discussion 9–80.
Correspondence: Isabel Moreno-Hay, Department of Dentistry,
Universidad Rey Juan Carlos, Avenida de Atenas, s/n, Alcorcon,
Spain.
E-mail: isabelmorenohay@gmail.com
© 2015 John Wiley & Sons Ltd