Journal of Oral Rehabilitation 2000 27; 802–807
Cephalometric estimation of Vertical Dimension of
Occlusion
J.-D. ORTHLIEB, M. LAURENT & O. LAPLANCHE
Marseille, France
SUMMARY The literature does not establish a single
proven method for determining lower facial height,
which is called the Vertical Dimension of Occlusion
(VDO), and the concept of a vertical comfort range
is generally accepted. This study aimed to test the
statistical significance of correlations of mandibular
shape versus lower facial height in occlusion, using
cephalometric measurements. Correlations for 505
consecutive healthy adults were calculated be-
tween angles that estimate the lower facial height
Introduction
In the Glossary of Prosthodontic Terms (1994), the
Vertical Dimension of Occlusion (VDO) is the lower
facial height measured between two points when the
occluding members are in contact. Another definition
is more precise: VDO refers to the vertical position of
the mandible in relation to the maxilla when the upper
and lower teeth are intercuspated at the most closed
position. Dawson (1989) distinguished passive VDO
and active VDO, which is characterized by an intense
contraction of closure muscles.
Valentin & Yakhou (1993) reported that the VDO is
the superior limit of the rotation closure movement of
the mandible and that, in variations, the VDO is turned
around the bicondylar hinge axis defining a rotation
angle (Fig. 1). Because there is only one VDO relating
to the entire mandibular corpus, it would be wrong to
describe an anterior and a posterior VDO. Thus, it is
possible to state a clear difference between the loss of
VDO and the loss of occlusal posterior support. Okeson
(1989) pointed out the frequent confusion between
these two situations.
© 2000 Blackwell Science Ltd
UFR Odontologie, Université De La Méditerranée,
and angles that estimate the mandibular shape. The
mandibular angle (gonial) showed a higher coeffi-
cient of correlation (r= 0·691) than the inferior go-
nial angle. The dispersion remained large, i.e.
r 2 = 0·478. Cephalometric measurements, despite
theirs imperfections, could help the practitioner to
understand what the best course of treatment
would be in order to obtain a lower facial height in
occlusion showing a skeletal harmony with the
mandibular shape.
When fabricating an extensive fixed bridge or a com-
plete denture, the dentist needs to make a decision
about the VDO. Is it possible to close it in order to
decrease the crown:root ratio? Is it possible to increase
it in order to improve retention on the abutment?
Although variations of VDO have not been statistically
correlated to temporomandibular disorders (TMDs)
(Seligman & Pullinger, 1991), it is still considered pru-
dent for a patient who requires prosthetic treatment to
try and establish an appropriate lower facial height.
There are numerous clinical methods for determin-
ing the VDO. The value of the lower facial height is
routinely estimated by aesthetic analysis and clinical
determination of the rest position. The so-called ‘rest
position’ is represented by numerous mandible pos-
tures when subjects are quietly seated or standing.
There is a rest area rather than a ‘magic’ point of rest;
the free way space presents a large range (Atwood,
1956; Tallgren, 1972; Rugh & Drago, 1981). Drago &
Rugh (1982) reviewed the instrumentation employed
in the measurements of lower facial height, ranging
from simple millimeter scale and Boley gauges to
cephalometric, telemetric and magnetic methods. They
802

Fig. 1. The VDO variations (A
and B) were turned around the
bicondylar hinge axis defining a
rotation angle. (After J. B.
Dufresne.)
found that none of them have a sufficient reliability
and reproducibility to ensure that the practitioner has
recorded the right VDO.
The reference points found on soft tissues are not
stable and definite; therefore, the use of bone reference
points increases the accuracy of the measurements
(Drago & Rugh, 1982). Edwards et al. (1993) recalled
that radiographic cephalometry has been used as a
diagnostic tool in prosthodontics for over five decades,
and that costs and radiation exposure are low. Numer-
ous authors, e.g. Ricketts (1981), McNamara (1984)
and Slavicek (1984) developed and computerized these
techniques. Cephalometric analysis can provide not
only the VDO but also the orientation of the occlusal
plane, the curve of Spee, the anterior teeth position
and the anterior guidance. Edwards et al. (1993)
showed that the use of computerized analysis of VDO,
using simple mean references, is not very credible.
It seems reasonable to accept an alternative hypothe-
sis that the correct or physiological VDO can be better
described as a range instead of as a fixed point.
Nonetheless, the width of that comfort zone may vary
among individuals and in a single individual at differ-
ent times, because the individual adaptive capacity is
unknown (Rivera-Morales & Mohl, 1991).
Considering the amount of work involved, the ex-
pense and the irreversibility of some forms of extensive
prosthetic treatment, the importance of establishing
and evaluating the VDO continues to be an important
issue. The study of the osseous morphology, especially
the mandibular shape, of a patient could help practi-
tioners in prosthodontic treatment because the mor-
phology of the mandible is independent of its position.
Mandibular shape, as described by Ricketts (1981), can
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 802 – 807
CEPHALOMETRIC ESTIMATION OF VDO 803
be measured by the mandibular angle (gonial) and the
mandibular arch. These angle assessments are easily
obtained using lateral cephalometric X-rays.
The initial hypothesis of this study was as follows:
does a strong correlation exist between the morphol-
ogy of the mandible and the lower facial height
(VDO)? A regression formula could be proposed. Using
this formula, it may be possible to compare the calcu-
lated VDO with the real VDO of the patient and to
answer, for example, the following question: does the
increase of the VDO improve the skeletal harmony
between the mandibular shape and the lower facial
height of the patient?
The objective of this report, which uses cephalomet-
ric measurements, was to test the statistical significance
of correlations between mandibular shape and lower
facial height in occlusion.
Material and methods
In the 1980s, a large collection of lateral cephalometric
X-rays of consecutive white patients was collated in
Austrian dental clinics. Five hundred and five adult
cases were selected from this collection of data, in
relation to the absence of extensive dental restorations,
the absence of any orthodontic treatment and suitable
film quality (all of the landmarks had to be clearly
visible). Our sample was composed of 278 women
(55%) and 227 men (45%). The mean age was
31·01 years (s.d. 10·9). Ricketts cephalometric analysis
(Ricketts, 1981) was carried out using the ‘Cadias’®
program,* which enabled skeletal type definition of
* Gamma, Wien, Austria.
804 J . - D . O R T H L I E B et al.
Fig. 2. Superior angle (VDO sup): the superior angle is measured
from the condylar point to the ANS and to a posterior chin point
(intersection point of inferior cortical and posterior cortical).
each patient in a vertical direction (normal bite, open
bite, deep bite) and in a sagittal direction (class I,
class II, class III) (Slavicek, 1988; Jacobson, 1995).
The lower facial height in occlusion was measured by
four angular values: a superior angle, a median an-
gle, an inferior angle and the Frankfort mandibular
Fig. 3. Median angle (VDO med): the median angle is measured
from the Xi point to the ANS and to the pm point.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 802–807
Fig. 4. Inferior angle (VDO inf): the inferior angle is measured
from the Gonion point to the ANS and to the chin point.
angle (FMA) (Figs 2–5). The mandibular shape was
measured by two angular values: the mandibular an-
gle (gonial) and the mandibular arch (Figs 6 and 7).
The cephalometric angles were measured for each
of the 505 subjects, in units of degrees and millime-
ters, by the same operator. In a few cases, certain
cephalometric landmarks that were too difficult to in-
terpret were not recorded; therefore, there are some
missing values in the statistical data. The statistical
Fig. 5. The FMA is measured between the mandibular and the
Frankfort plane.

Fig. 6. Mandibular arch (M arch) is the complementary angle
from the Xi point to the condylar point and to the pm point.
analysis was obtained with classical descriptive analysis
(mean, s.d., range, s.e.). Correlations in simple regres-
sion were computed. A significant association is pro-
posed if PB 0·0001 and the amount of variance is
accounted for by r 2.
Fig. 7. Mandibular angle (gonial): the mandibular angle is mea-
sured from the Gonion point to the articulare point and to the
chin point.
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 802 – 807
CEPHALOMETRIC ESTIMATION OF VDO 805
Results
Descriptive analysis
Table 1 shows the descriptive statistical values of the
six studied angles:
1. Superior angle of the VDO (VDO sup): the angle is
described from the condylar point to the anterior
nasal spine (ANS) and to a posterior chin point
(intersection point of inferior cortical and posterior
cortical) (Fig. 2). The mean was around 40°, the
standard deviation was relatively narrow (3·88) in
comparison with the others and the values were
ranged only on 24°.
2. Median angle (VDO med), ANS–Xi–pm angle. This
angle measures the lower facial height from the Xi
point to the ANS and to the pm point (Fig. 3)
(Ricketts, 1981). The mean was 43° and the s.d.
was 5·56.
3. Inferior angle (VDO inf): the inferior gonial angle
measures the lower facial height from the Gonion
point to the ANS and to the chin point (Fig. 4)
(Orthlieb, 1990). The mean was 48·5°, the s.d. was
5·21 and the range was the largest found (46°).
4. FMA: used by Tweed (Jacobson, 1995), this mea-
sures the antero-superior angle between the
mandibular and the Frankfort plane (Fig. 5). The
mean was 23° and the s.d. was 6·56.
5. Mandibular arch (M arch): measures the mandibu-
lar shape with the complementary angle from the
Xi point to the condylar point and the pm point
(Fig. 6) (Ricketts, 1981). The mean was 36·5° and
the s.d. was 6·88.
6. Mandibular angle (gonial): this angle measures the
mandibular shape from the Gonion to the articu-
lare and to the chin point (Fig. 7). The mean was
126° and the s.d. was 7·09.
Correlations
Correlations in simple regression were calculated be-
tween the four angles that estimate the lower facial
height and the two angles that estimate mandibular
shape (Table 2). The coefficients of correlation were
between 0·691 and 0·438.
The correlations were always statistically significant
(PB 0·0001); however, even in the best correlation,
the dispersion remained large. In this case, r 2 (0·478)
806 J . - D . O R T H L I E B et al.

Table 1. Descriptive statistic values

VDO sup VDO med VDO inf FMA M arch Gonial

Mean 39·5 43·44 48·46 23·03 36·42 126·38

s.d. 3·88 5·56 5·21 6·56 6·88 7·09
Count 482 504 482 505 503 482
Minimum 30 30 31 3 18 103
Maximum 54 64 66 45 62 149
Range 24 34 46 42 44 46
s.e. 0·177 0·248 0·237 0·292 0·307 0·323
Interquartile 5·00 7·00 7·00 8·00 9·00 10·00
Missing 23 1 23 0 2 23

VDO sup: superior angle de Sanial; VDO med: median angle, ANS–Xi–pm angle of Ricketts;
VDO inf: inferior angle, inferior Gonion angle; FMA: Frankfort mandibular angle; M arch:
mandibular arch of Ricketts; Gonial: mandibular, angle.

showed that only 50% of the variance of the VDO is
explained by the mandibular arch angle.
Simple regressions were computed for the different
subpopulations in relation to the skeletal type classifica-
tion (openbite, deepbite, class II, class III). The results
were not more significant.
Discussion
In the literature, none of the proposed techniques have
been proved to be scientifically accurate or superior and
scientific research has only succeeded in destroying the
old myth of a ‘magic’ lower facial height in occlusion
(Rivera-Morales & Mohl, 1991) The dispersion values
of the six measured angles of the VDO ranged from 3·88
to 7·09. Cephalometric studies have always showed
large data’s dispersions (Orthlieb, 1990), this dispersion
not only being related to individual variations but also
to picture deformations, superposition of structures and
the inaccuracy of cephalometric tracing. In light of
these large dispersions, the results must not be clinically
applied dogmatically. This study confirms the results of
Edwards et al. (1993) who, using only mean values,
showed for all four tested methods a large variation and
inconsistent findings with the subject’s existing VDO.
They further stated that the four vertical dimension
programs used (SAM-AXIOCOMPT®) were not reliable
in the population studied. In relation to the inaccuracy
obtained with the use of mean values, correlation anal-
ysis showed more interesting results.
The mandibular angle (gonial) versus the VDO inf
angle showed a higher coefficient of correlation (r=
0·691). Therefore, following the cephalometric mea-
surement of the mandibular angle (gonial), it may be
possible to estimate, by calculation, the subject’s ideal
VDO using the regression formula VDO inf = 0·508 ×
(gonial −15·7). Correlations were more interesting
than mean values because they were more specifically
related to the patient. However, the dispersion re-
mained very large because r 2 = 0·478. Therefore, these
results are insufficient to claim a very accurate measure
of the VDO. The concept of a vertical comfort range is
generally accepted; it could explain the dispersion of
the data (Rivera-Morales & Mohl, 1991) or, the reverse,
the dispersion of the data could explain the concept of
a vertical comfort range.
The VDO is the result of a musculoskeletal balance
during growth. The skeletal morphology of the
mandible is clearly related to the elevator muscles’
organization. Therefore, in relation to an inaccurate
measuring instrument, we can propose, in order to
evaluate the VDO, a pluralistic method of calculation
using several regression formulae to try to compensate
for the inaccuracy by comparison with several estima-
tions. It is possible to calculate different estimations of
the VDO from the two measurements of the mandibu-
lar shape using the different regression formulae pro-
posed in Table 2. If these calculated values indicate the
same direction (increase the VDO, for example), the
corroborating facts could help the clinical decision con-
cerning the vertical dimension. This new hypothesis
must be tested in future research.
Vertical dimension of occlusion is one of the determi-
nants of prosthetic reconstruction, and cephalometric
analysis can also help in decisions concerning the orien-
tation of the occlusal plane, the curve of Spee, the
anterior teeth positions and the anterior guidance (Or-
thlieb, 1997).

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 802–807

 CEPHALOMETRIC ESTIMATION OF VDO 807

Table 2. Correlation table

(simple regression) n r r2 F T PB Regression formula

Gonial – VDO inf 482 0·691 0·478 438 20·9 0·0001 a= 0·508×b−15·7
Gonial – FMA 482 0·655 0·429 361 19 0·0001 a =0·607×b−53·5
M arch – FMA 503 0·642 0·413 351 18·8 0·0001 a=−0·614×b+45·4
M arch – VDO med 502 0·573 0·329 244 15·6 0·0001 a=−0·463×b+60·3
M arch – VDO inf 481 0·575 0·330 236 15·4 0·0001 a =−0·433×b+64·2
Gonial – VDO med 481 0·438 0·192 113 10·7 0·0001 a =0·343×b+0·26
M arch – VDO sup 481 0·362 0·131 72 8·5 0·0001 a=−0·204×b+46·9
Gonial – VDO sup 482 0·324 0·105 56 5·6 0·0001 a =0·178×b+17·1

VDO sup: superior angle de Sanial; VDO med: median angle, ANS–Xi–pm angle of Ricketts; VDO
inf: inferior angle, inferior Gonion angle; FMA: Frankfort mandibular angle; M arch: mandibular
arch of Ricketts; Gonial: mandibular angle.

The use of statistic formulae applied to cephalometric
analysis is not a very accurate science because of the
dispersion of the results. However, clinical feelings are
also inaccurate and are related to the experience of the
practitioner. The practitioner must not be a slave to the
numbers; he needs them to help and to educate him if
he is to draw up a plan for future prosthetic treatment.
Cephalometric analysis can give information, not on a
precise position of the VDO but only on the direction of
the treatment.
Conclusion
The literature review shows that there is no ‘magic’
method for the evaluation of the VDO. The concept of
a vertical comfort range is generally accepted and, in
fact, for a patient, the real question is in which direc-
tion does the variation of VDO (increase or decrease)
lead to the best harmony of its musculoskeletal deter-
minants. It is easier to assess skeletal morphology than
muscles. Therefore, cephalometric analysis, despite its
imperfections, may help the practitioner to understand
the direction of the treatment concerning the lower
facial height in occlusion.
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Correspondence: Dr Jean-Daniel Orthlieb, 307 rue Paradis,
13008 Marseille, France. E-mail: jdo@gulliver.fr

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 802 – 807