Charles l.

Edwards, DC, USN•

Camp leieune, North Carolina

Mar' W. Richards. DC, USN••

Edward 1. Billy, DC, USN•••

Using Computerized
Lionel C. Neilans, DC, USA" • •
Cephalometrics to Analyze
the Vertical Dimension of Naval Dental School
National Naval Dental Center
Occlusion BQtheua, Maryland

A computer program that uses cephalometric analyses for

determining the patient's occlusal vertical dimension has
recently been introduced. Data generated from this computer
implies changes in incisal-pin position for articulated casts.
This study evaluated the accuracy of this vertical•dimension
program using 24 completely dentate, white male subjects with
clinically acccptable occlusal vertical dimensions. A
cephalometric radiograph was made, and measurements from
the tracing were entered into the computer for analysis.
Recommended incisal-pin changes ranged from —11 to + 25.3
mm, with a mean Change of 8.4 mm for all methods tested.
These results showed a low correlation with each subiect's
clinically determined occlusal vertical dimension. Int 1
Prosthodont 1993;6:371-376.

n dentistrv, there is no accurate sciemific method for
determining the occlusal vertical di-mension (OVO). T
his determination must be made subjectively, based
on the experience and judg-ment of the dentist.' A
precise technique for deter-mining OVD v•.ould greatly
assist the experien¿ed
and inexperienced dentist alike.
Radiographic cephaiometry has been used as a
diagnostic tool in prosthodontics for over five de-
cades.' Most previous cephalometric studies fo-
cused on studying mandibular rest position' and
measuring the changes in vertical facial height.h•'
• 2nd Dental Compam.
• • Chañan. Prosthodonrics Deparrment.
• •Chatrman. Prosthodonucs Deparrmenr. Chairman. Orthodonucs
Department.
The orassert:ons contained 'n thrs artwle are the private
one of the authors and are not ro be construed as off:cial or as
reilecong che views of rhe Department of the Navs. Dcpartmcnt• of
Defense, or the US (30' ernment.
Recently, a computer-assisted cephalometric pro-
gram (SAM AXIOCOMP, Praezisionstechnik, Mu-
nich, Germany) that applies cephalometric
analysis as an obiective method of determining
OVD was introduced. The program compares a
patient's measured cephalometric landmarks with
averages found in the general population.
Mathematical computations project these findings
to the incisal pin of the SAM 2 articulator
(Praezisionstechnik). Proprietary software then
measures OVD by four different techniques. The
techniques" were devel. oped by Ricketts.•
Slavicek,"' McNamara,» and
Harvold'l to compute the patient's optimum OVD.
To date, clinicians have had to arbitrarily select
one of these four methods.
The purpose of this study was to compare the
four methods in the SAM AXIOCOMP computer
program to determine which method is most
accu-rate in calculating OVD on subjects with
clinically acceptable OVDs.
Materials and Methods

Reprint reqcrsts.• Capt Sfark

Richards. DC. USN. Prosthodon. Twcnty•four White men, aged 22 to 40 years
trcs Depantnent. Naval Dental School. N'dtional Naval
Dental Centen Bethesda. .Varvland 211889-5077. (mean age 27.9 yearsl, whose existing OVDs were

Volume6, Number 4. 371 The In•ernational Journal oi

 ( :otnputerized Cephaloml'tri( Anal».... Edwards "t al

Fig2 Hinge ax•s marked with a metal ball to facilitate Icxathn

FM The SAM 2 articulator. of axis

plane.

and tracing.
Fig3a Cephanmetric landmarks. Fi93b Cephalometric

determined to be clinically acceptable, were se-lected
to control ethnic origine gender, and growth
variables. To rule out unnatural skeletal relation-
ships, an OVD was determined to be clinically
acceptable if the subiects had no history of ortho-
dontic treatment, orthognathic surgery. temporo-
mandibular dysfunction, facial trauma, or mandib•
ular fracture. The subiects were also required to have
a complete complement oí teeth, with no removable
or fixed prosthcses and littlc or no oc-clusa' wear.
Assessment of a subject's existing ()VD was made
independently by three prosthodontists certified by
the American Board of Prosthodontics. -traditiondlly
accepted techniques were used to evaluate esthetics
and symmetry,-' phonetics,•
closest speaking vertical dimension of rest,
and interocclusal rest Only thosc subiects
whose existing OVDs met all the above criteria
were accepted for the study.
Diagnostic casts were made using irreversible
hydrocolloid impression material (Jeltrate Plus,
Typc II, LD Caulk, Milford, DE) and poured in an
improved stone (Silky Rock, Whip Mix, Louisville,
K Y). These casts were Ihen articulated on the SAM 2
articulator (Fig 1) in maximum intercuspation at the
incisal-pin reference mark, The reference mark lo-
cated on the lower member of the articulator repre-
sents the subiect's existing OVD from which adjust-
rnents are made based upon recommendations by
the vertical dimension program.
The International 'ournal ot Prosthndont.cs 372 Volume h. Nilmbt
 Edv.ards et al
Computertzed (_-ephatornetrac Analvs•s

1 Example of Data Input Into SAM AXIOCOMP Computer and

for Change 01 Incisal-Pin Position by Cephalometric Methcxi

WIIca1 dirnension

facial height

Facial axis 89 Rickers•Sfawcek

Facial depth 88

F.nandibular plane Actual

Mandibular arc

CondyIion-PtA Dtfference

Nas ven-PtA 2 mm Incisal gn

128 mm

W) mm

CMWyIion-gnath•on HzWd-McNamara I

Menton-ANS 80 mm Calculated

Menton-PtA 70 mm Actual
Spina nasal± anterior

Irxisal Pin

XI Z = 33 mm

X = 93 mm Harvdd•McNamara tl

X Z - 38 mm Calculated

PM = 8 mm Actual

X - 69 mm Z

Difterence

Incisa pin

Ricketts

Cakxlated

Actual

Incisal pen

cephalometric landmarks (Fig 3a) have been

To facilitate location of axis orbital plane, the
transverse horizontal axis was found using a Uni-
versal I linge Axis Recorder (Loma Linda Alloy, Loma
Linda, CA) and marked with a metal ball (Beeklev
Spots, Bristol, CT) (Fig 2). Cephalometric radio-graphs
were made with the subject's teeth in maxi-mum
intercuspation at standardized exposure settings of 75
kVp. 10 mA, and 0.8 seconds, using an ORIHOCEPH 10
(Siemens Medical Svstems, Dental X-Ray Div,
Charlotte, NCJ. Kodak Ortho L 'Eastman Kodak,
Rochester, N Y J film was used with Oinch source-to-
obiect and 8-inch subject-to-film distances. The
described by Ricketts• and Chaconas and Gonidis-•-
All tracings (Fig 3bJ were made with the patient's
profile facing to the right, as recom-mended by the
Second Cephalometric Workshop•.
Measurements from cephalometric film tracings
were entered into the computer's vertical dimen-Sion
program (fig 4). This program is a part of the
AXIOC()MP software that runs on a unique propri-
etary computer program. For each of the four
methods, the program provides incisal-pin changes
from the reference mark on the SAM 2 articulator.
These incisal-pin changes are derived from the dif-
terences between the actual and calculated values. The
actual values are the measurements made di-rectly
from the subject's cephalometric tracings and
represent the patient's existing OVD. The cal-culated
values arc the measurements of the sub-ject's
predicted OVD as determined by the com•

Fis 4 The SAM AXIOCOMP compa.ner.

puter. The difference between the actual and

calculated values represents a positive or negative
change in the vertical height of the SAM 2 articula-
tor's incisal pin- The incisal pin can then be ad-justed
to one of the program's calculated values to position
the mandibular cast at the recommended OVD. The
incisal-pin table of the SAM 2 articulator is located on
the upper member; therefore, a nega-tive ditference
represents an increase in OVD. For example, it the
Ricketts/Slavicek method were used and the
computer's calculated value were —4 mm, the incisal
pin would be positioned 4 marks (mm) below the
reference mark, thereby increasing the OVD by 4 mm
at the incisal pin. A printout with data for each method
was analyzed for all 24 subiects fable 1). The
difference values in mm for each

. Iolume 6. Number 4, 193 373 The International lournal oi Proqhodontics

 Computerized Cephdlome«ric Fdv,ards et al

Recommended Incisal-Pin (mm)

Method

Ricketts

Ricketts Harvold' Harvold/ {divine Range

Subject Slavicek McNamara I McNamara II

4.4 3.0 2.0 14.2

2 9.6 9.4 - 5.0 2.8 19.0

3 5.5 10.3 - 10.0 -9.8 15.8

4 11.0 4.8 2.5 6.0 15.8

62 7.8 6.5 6.7 1.6

6 3.0 - 8.9 0.2 - 13.8

5.2 16.8

7 0.6 - 5.3 -10.0 10.6

8 1.4 - 12.6 6.2 -8.9 14,0

9 5.8 - 12.6 3.4 — 4.4 18.4

10 13.6 - 25.3 2.8 -22.2

15.8 11.6

-6.8 15.2

5.2 - 10.2

12 - 10.2 -23.5 - 15.5 - 24.8 14.6

23. I

13 3.8 - 19.3 - 10.1

14 9.4 - 2.9 -11.2 20.6

-8.9 — 16.4 6.5

15 -2.0 -8.5 - 2.8 — 4.8

16 — 4.6 -5.3 10.0

0.0 - 10.0 - -7.6 15.2

17 _ 5.4 14.5 0.7 10.7

18 3.2 - -6.5 -2.2 10.8

19 —4.8 — 20.4 -124 15,6

20 5.0 7.8 -0.1 -7.7 12.8

21 2.6 3.5 29 -7.3

22.9 mm).10.6
22 -11.0 130 1.6 -8.6
11.4

17.0

23 -11.2 205 6.6 23.6

14.0

24 -1.6 12.7 9.0 15,6

method were averaged, and the median changes Tabk3 Recommended Incisal-Pin Changes (mm)
were computed. SD••
Mean
Method' Rarge
 Results
-25.3to

In this study, the zero point on the incisal pin Ricketts• Slavicek 115.638 36.8216 - 13.6 117.08

was the patient's existing OVD, which had been HangoldfMcNamara I

deter-mined to be clinically acceptable. T his
point served as Harv04dtMcNamara II 5.45 4.52
the control to which all calculated values were
-15.eto 6.5
compared. The changes in OVD recommended by 10.94

each of the four cephalometric methods used in Ricketts (divine pmorMn) 617 -24.et0 6.7
the SAM AXIOCOMP program are listed in lable 2.
Positive values indicate that the OVD should be values

decreased at the incisal pin with respect to the
patient's existing OVD, while negative values indi-
cate that it should be increased. Of the 96 incisal
pin Change values obtained, 78% were negative.
suggesting
that this population group exhibited a
deficiency
in OVO. The mean recommended
incisal-pin changes {Table 3) suggest that the
Ricketts/Slavicek and the Harvold/McNamara II
methods were similar and resulted in smaller
incisal-pin changes than the Harvold/McNamara
I or the Ricketts (divine proportion) methods.
The data, however, are highly variable. The rec-
ommended incisal-pin changes varied greatly from
method to method for each patient and ranged from
1.6 mm (patient 5) to 23.1 mm (patient 13) {Table 2),
with a median recommended incisal-pin
• Absoluten-24 sthjeCIS par m.etFM?KS
Change of 14.4 mm. The variability within each method
for all patients was also high,as indicated by the
standard deviations and ranges shown in Table 3. The
ranges of the recommended incisal-pin changes for
the RickettsSlavicek method totaled 24.6 mm (median
16.4 mm), those for the
Harvold/McNamara I method totaled 33.1 mm
{me-- 15.2), those for the Harvold/McNamara
II
method totaled 22.3 mm (median = 11 mm), and
those for the Ricketts (divine proportion) method
totaled 31,5 mm (median
Discussion

An accurate evaluation of facial vertical dimen-sion

is essential to the success of a prosthesis. The
prosthodontist cannot indiscriminately increase or
decrease the OVD beyond the patient's physiologic
requirements.•' IJsing accepted criteria, the sub-

The lournal of
374 Volume 6, Num
 Edwards et al
jects in this study were determined to have physio•
logically acceptable ()VDs. Studies have shc»vn that
oral rehabilitation at an increased OVD can cause
postoperative problems and should be avoided.-
Experimental evidence on animals and corroborat-ing
clinical evidence have shcnvn that increasing the OVD
can cause intrusion ot posterior teeth. v' Tryde
- in determining the OVD in edentulous
patients. coined the term "comfort zone" tor the
range "'ithin which patients can tolerate OVD
changes. The average comfort zone was relatively
narrow: ie, 1.3 mm. Dawson
and Turner and
Missirlian* recommend changing the OVD only if
absoluteiv necessarv to provide space for restor-
ative materials, and then bv onlv the minimal
amount required (1 to 1.5 mml. These studies pro-
vide evidence that large «-hanges in OVD should be
avoided.
Table 3 shows recommended incisal-pin changes for
all methods, ranging from —11 to + 25.3 mm. "'ith a
mean Change oí 8.4 mm. It should be noted that an
()VD change at the incisal pin results in a smaller OVD
change at the molar area. The arc of closure Will cause
the amount of increase in OVD to decrease posteriorlv.
depending on the position of the cast v.'ithin the
iramework of the articulator as determined during the
iacebow transfer. Measure-ments of the articulated
casts indicated an average increase of OVD in the
molar area of hali the value of the increase at the
incisal pin for the SAM 2 articulator: a 6-mm increase
in OVD at the incisal pin results in a 3-mm increase at
the molar leve' (Fig 5). If this factor is considered and
recommended changes are reduced in half, the results
Still place only 13% oi the findings within the comfort
zone. A recent review of the literature on OVD
changes• concluded that current scientific knowledge
does not support the hvpothesis that moderate
changes in OVD are detrimental to the health of the
mastica-torv system. However, the OVD changes
calculated by this study are so large that they cannot
be con-sidered clinically acceptable without
confirming clinical data. The large standard deviations
and ranges indicate the inconsistencies of the current
SAM AXIOCOMP vertical-dimension programs, making
their validity and usefulness questionable.
Although computerized cephalometric programs
mav someday have the ability to provide a more
objective scientific method for determimng OVD.
these programs must be refined to give consistent
and clinically useful data. The use of average or
"normative" measurements upon which these pro•
grams are based may be a source of error.
McNamara" used 111 young adult men and women in
the Ann Arbor, Michigan, area as the sample for
. .»me 6. Numtrr 4. 193 375
Computenzed Cephdlometric
i
5 %rtical dimen50m of opened 6 mm at incisal
pin on SAM 2 articulator.
his study's composite norms, whereas Rickettsl-used
adult Peruvian men in his divine-proportion analysis.
The more specific population group of white males
used in this study may require a differ-ent set of
composite normative standards than does
a mixed population group. Population groups by
themselves may not be specific enough to provide the
accuracy needed. Each patient is an individual and
follows a bone growth pattern that is deter-mined by
familial and hereditary factors. Consider-ing the large
number of variables, it is possible that average
measurements cannot be used. The pa-tient's
musculature is considered to be the deter-mining
factor in facial vertical dimension and may well be the
most important factor.
tx [n addition, the
patient's physiologic and psychologic well•being
play an important role. These factors may be so
important that the use of cephalometrics alone
cannot provide an accurate determination of OVO.
Other possible sources of error must also be con-
sidered, eg. differences in radiographic distortion
from using different x-ray machines and human
error in the manual tracing oí cephalometric radio-
graphs. The author of the software used indicates
that additional data on racial variations Will be in-
corporated into a revised edition of the software
utilizing differing normative standards (Wirth C,
personal communication, April, 1991). Improve-
ments in the quality oí cephalometric radiographs
are needed to give more reliable location of refer-
ence marks. Further studies with different popula-
tion groups and norms are required to ascertain
whether accurate and clinically useful computer
programs for evaluating OVD can be developed.
Conclusion
A computerized program using four cephalomet-ric
methods for determining OVD was studied.
The International lournal at
 Computer•zed Cephabomelnc Analysis Edwards ot al

These methods were compared using 24 dentate 12. Bodine TA. A study of vertical and centric relations means

subiects whose OVD was determined to be accept- 13.
774. Basler Fl., Douglas IR, Moulton R.S. (.•ephalometric analysis 01
able. Data from cephalometric tracings were ana-
the vertical
lyzed by the SAM AXIOCOMP computer program, 14.
and findings were related to changes in the incisal
pin of the SAM 2 articulator. Under these condi-tions
certain conclusions may be made. Recom-mended 1.5.
incisal-pin changes for all four methods
demonstrated large variations and inconsistent
findings with the subiects' existing OVD. A mean
recommended incisal-pin Change of 8.4 mm was 16.
found. with 78% of the findings suggesting a defi-
ciency in OVD for this population group. The four 17.
AXIOCOMP vertical-dimension programs used were
not reliablc in the population group studied. 18.
Ackrwwledgments
19.
This proiect was supported under Naval Medial Research and
Devetopment Command Work Unit No.
20.
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Thc International Journal of Prosthodontics 376 Volume 6, Numu