Role of Cephalometery in evaluation of vertical dimension

ORIGINAL ARTICLE

ROLE OF CEPHALOMETERY IN EVALUATION OF VERTICAL DIMENSION

1

KHEZRAN QAMAR, BDS, FCPS

2
USMAN MUNIR, BDS, FCPS
3
SAJID NAEEM, BDS, FCPS

ABSTRACT
The objective of the present study was to determine the vertical dimension by comparing hard and
soft tissues through lateral cephalographs. To show that these measures are compatible with the
routinely used methods plus records for future complete denture fabrications. It is a descriptive study
and was carried out at the Prosthodontic Department of Lahore Medical and Dental College, Lahore
from July 2011 to January 2012.
A total of twenty completely edentulous patients of both genders were selected and age range was
40 years and above. Demographic data and informed consent of all the patients were obtained. The
exclusion criteria included any facial asymmetry, congenital and acquired orofacial deformity and
patients not willing to undergo radiography. The cephalographs of each patient was carried out at 2
stages, before and after the insertion of the complete dentures. With the help of lateral cephalographs
the hard and the soft tissues were compared. The Rickets cephalometric analysis was to analyze the
hard tissues from both the first and second lateral cephalographs for measuring the vertical
dimension. The Burstone analysis was used to analyze the soft tissues.
The results of the present study showed that the pre and post difference of the skeletal proportions
when compared from both the cephalographs was insignificant .Furthermore the stability in the
skeletal vertical dimension was observed in Pakistani population. In addition the soft tissue
proportions remained near 1 (G-Sn/Sn-Me).
It was concluded that the lateral cephalographic method can be used to evaluate the vertical
dimension in the Pakistani population and is complementary to the routinely used methods for the
complete denture fabrication.
Key Words: Vertical dimension, Cephalometery, Edentulisim, Facial proportions.
INTRODUCTION
The patients among the lower socioeconomic groups
especially in rural areas may become edentulous at
relatively earlier ages, hence requiring prosthesis to
carry out oral functions.1 The long term edentulous
patients also presented with changes in soft tissues
profile as well as loss of vertical dimension.2
1

2
3

Assist Prof Prosthodontics, Lahore Medical &Dental College,

Lahore, Postal Address: 286 /D, St #12, Askari 10, Lahore Cantt,
Pakistan. E-mail: drsajidnaeem@hotmail.com
Phone No.: 042-36500082, 0300-4577548
Assist Prof Prosthodontics, Phone No.: 03004589893
Prof Prosthodontics, Postal Address: 213-B, Revenue Employees
Cooperative Housing Society, Lahore, Pakistan.
E-mail: drsajidnaeem@hotmail.com,
Phone No.: 042-35185858, 0300-4245331
Received for Publication:
Revision Received:
Revision Accepted:

November 15, 2012

February 10, 2013
February 16, 2013

Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

The basic objectives of complete denture prosthodontics are the restoration of facial appearance, function and the maintenance of the patients health and
masticatory ability.3 This could be achieved by taking
correct impressions and recording accurate
maxillomandibular relation records. One of the records
among the maxillomandibular records was recording
vertical relation4, defined as the points on the maxilla
and mandible when the teeth are in maximum
intercuspation.5
Patients speech, appearance and mastication all
depends on recording appropriate vertical relation.6
Different facial references such as center of the pupil
to the corner of the lips, minimal speaking space, from
glabella to base of ala, has been used to measure the
vertical relations.7 unfortunately soft tissue based
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Role of Cephalometery in evaluation of vertical dimension

facial references are not stable and show variations

with increasing age. 8However cephalometric analysis
had been used to relate craniofacial land marks to
profile and occlusion in a meaningful way.8 Among the
most used were the Rickets and McNamara cephalometric analysis that had been employed to record occlusal vertical relations by using stable and reproducible bony landmarks.9
The aim of this study was to determine the vertical
dimension of edentulous patients by using lateral
cephalography. This may contribute in recording vertical dimension of edentulous patients in a simple,
inexpensive and atraumatic way.
The same vertical dimension may also be used for
future prosthetic reconstruction. Furthermore this
method may also be complementary to the routinely
used methods prescribed for the complete dentures
fabrication.

The Burstone analysis was used to evaluate the soft

tissues.
HARD TISSUE REFERENCE POINTS
Following hard tissues land marks were considered;9

ANS (Anterior nasal spine): Anterior point of nasal floor; the tip of the pre maxilla in the mid
sagittal plane.

Me (Menton): Lowest point of contour of mandibular symphysis.

N (Nasion): Most anterior point of fronto nasal

suture in mid sagittal plane. (Fig 1)

SOFT TISSUE REFERENCE POINTS

G (glabella): The most prominent point in the mid

saggital plane of the forehead.

Me (soft tissue menton): Lowest point on the contour of the soft tissue chin;

Sn (sub nasal point): The point at which the nasal

septum merges with the upper cutaneous lip in the
mid saggital plane. (Fig 2)

METHODOLOGY
In this study a total of 20 edentulous patients
seeking complete denture treatment were selected
from the Outdoor Prosthodontics Department of Lahore
Medical and Dental College, Lahore. Ten male and ten
female patients were selected. The age range was 40
years and above. Demographic data and informed
consent of all the patients were obtained. The exclusion criteria included any facial asymmetry, congenital and acquired orofacial deformity and patients not
willing to undergo radiography.
Cephalography of the patients was carried out at
two stages. The first lateral cephalograph was taken
prior to the insertion of the complete denture while the
second lateral cephalograph after the insertion.
The cephalogram manufactured by Villa (Italy)
model number MRO5 with standardized ear plugs,
nose clamp and chin support was used to carry out
lateral cephalography. First lateral cephalographs of
patients were carried out where every patient was
asked to swallow and hold the mouth in relaxed closed
position without complete dentures.
Complete dentures were fabricated for all the
patients. After the insertion of the complete dentures
a second lateral cephalograph was taken.
Rickets cephalometric analysis was employed to
measure the vertical dimension from both the first and
second lateral cephalographs, by using linear measurement (Fig 1). The soft tissue structures taken for
the profile were the glabella, nose, lips and chin (Fig 2).
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

RESULTS
Out of 20 completely edentulous patients, 10(50%)
were female and 10(50%) were male. The average age
of the patients was 59.509.01 years. The proportion of
0.8 + 0.2 was present between the middle third and the
lower third facial heights (N-ANS/ANS-Me) Tab 1.The
stability in the skeletal vertical dimension was observed. In addition the soft tissue proportions was
obtained near 1 (G-Sn/Sn-Me) Tab 2. Significant difference in values was not observed in both pre and post
cephalograms of the same patient when compared.
DISCUSSION
The present study was an attempt to evaluate the
reliability and reproducibility of the relatively stable
cephalometric landmarks and their role in determining vertical dimension. However this study was not
applicable on patients with any congenital and acquired orofacial deformity, facial asymmetry or patients not willing to undergo radiography.
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Role of Cephalometery in evaluation of vertical dimension

cephalographs at 2 stages were carried out as in the

present study.
Bhat6 checked the reliability of the conventional
methods for recording vertical relations by considering lateral cephalograph as a standard method.
In the present study Niswongers method was used
to record the vertical dimension, and verified with the
closest speaking space method. The combination of
these methods was used to minimize the chances of
errors in recording the occlusal vertical dimension.
McCord15 also recommended the combination of different methods. Koller7 and Silverman16 used closest
speaking space method to verify occlusal vertical dimension.

Fig 1: Skeletal proportion between the middle and the

lower thirds of the face.

Fig 2: Soft tissue proportion between the middle and

the lower thirds of the face
Brzoza and coworkers9 had also carried out a
similar study to predict occlusal vertical dimension
through cephalometery in edentulous patients. Ciftci10
also used the same 2 cephalographs to record the
vertical dimension. Zeng and coworkers11 in year 2003
also used cephalographs to evaluate the lower facial
heights. They also used swallowing method to record
mandibular rest position.
Koller7 used swallowing method for recording rest
position. Pinto and coworkers12 and Tallgren13 and
Orthlieb14 in their study on edentulous patients checked
the vertical height through lateral cephalometery and
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

The skeletal landmarks used in the present study

to evaluate the proportion between middle and the
lower third through lateral cephalographs were (NANS/ANS-Me). Brzoza, Barrera, Contasti and Hernndez 9 had also used the same references and the soft
tissue proportion was obtained by considering G-Sn/
Sn-Me, just as in the present study. In the present
study a proportion of 0.8+0.2 was present between the
middle and the lower third and the stability in the
vertical dimension was observed (Fig 1). Similar results were shown in a study done by Legan and
Burstone.9 This value was obtained by dividing the
measure of the middle third between the one of the
lower third, being the first one little smaller than the
latter. Similarly Brzoza et al9 have reported similar
proportion in their study. Furthermore no significant
difference in values were obtained when compared
with lateral cephalographs of the same patient with
and without dentures as reported in the present study.
Ricketts analysis was used to analyze the skeletal
proportions and Burstone for the soft tissue proportions as done by Brzoza and coworkers.9 Orthlieb14 also
used Ricketts analysis to study lower facial height. It
was found that cephalographs could be used as a
reliable diagnostic aid in patients who had lost their
occlusal vertical dimension.
Brzoza Barrera, Contasti and Hernndez 9 in their
study used similar landmarks to measure the soft
tissue proportion as in the present study. The soft
tissue proportion obtained in the present study remained nearly 1+0.2 (Tab. 2) and this was observed
with and without dentures. The results of the present
study showed that and it was possible to predict the
vertical dimension through lateral cephalometery as
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Role of Cephalometery in evaluation of vertical dimension

TABLE 1: SKELETAL PROPORTION BETWEEN THE MIDDLE AND LOWER THIRD OF THE HEAD
WITH AND WITHOUT DENTURE
N

Minimum

Maximum

Mean

St.deviation

Skeletal proportion with denture

20

0.6

1.0

0.822

0.0881

Skeletal proportion without denture

20

0.6

1.0

0.812

0.1003

TABLE 2: SOFT TISSUE PROPORTION BETWEEN THE MIDDLE AND LOWER THIRD OF THE HEAD,
WITH AND WITHOUT DENTURE
N

Minimum

Maximum

Mean

St.deviation

Soft tissue proportion with denture

20

0.7

1.0

0.8

0.08231

Soft tissue proportion without denture

20

0.7

8.0

1.200

1.6039

the cephalometric landmarks were reliable and stable.

This method is also a simple and inexpensive method
that is complementary to the conventional methods
used to evaluate the vertical dimension.
This study coincides with the study done by Zeng
and coworkers11 who used swallowing method for recording vertical and cephalographs at 2 stages and
found no difference in values of both cephalographs
and concluded that swallowing method is an efficient
method of recording vertical.

Levin EI. Dental esthetics and the golden proportion. J Prosthet

Dent 1978; 40: 244-45.

Bloom DR, Padayachy JN. Increasing occlusal vertical dimension why, when and how. Br Dent J 2006; 200: 251.

Bhat VS, Gopinathan M. Reliability of determining vertical

dimension of occlusion in complete dentures. JIPS 2006; 6:
38-42.

Koller MM , Merlini L, Spandre G, Palla S. A comparative study

of two methods for the orientation of the occlusal plane and the
determinitation of vertical dimension of occlusion in edentulous
patients. J Oral Rehabil 1992; 19: 413-25.

Present study also coincides with the study done

by Bhat VS6 where he used Niswongers method and
concluded that this method had strong correlation
with cephalometric method.

Qamar R, Ahmad chaudry N. Cepahlometric characteristics of

class II malocclusion: Gender Dimorphism. Pak Oral Dent J
2007; 27: 73-78.

Barzoza D, Barrera N, Contadti G, Hernandez A. Predicting

vertical dimension with cephalograms for edentulous patients.
Gerodontology 2005; 22: 98-103.

CONCLUSION

10

Cifti Y, Kocadereli I, Canay S, Senyilmaz P. Cephalometric

evaluation of maxillomandibular relationships in patients
wearing complete dentures: a pilot study. Angle Orthod 2005;
75: 821-25.

11

Zeng JY, Yuan YS, Ma LA. Pilot study on jaw relation of

edentulous patients with digital cephalometric system.
Zhonghua kou Qiang Yi Xue Za Zhi 2003; 38: 113-15.

12

Pinto AS, Mollo FA Junior, Melo ACM, Chiavini PCR, Raveli

DB. Use of cephalometric cephalograms in the evaluation of
prosthetic treatment. Ortodontiae Ortopedia Facial 2000; 5
(abstract).

13

Tallgren A. The continuing reduction of the residual alveolar

ridges in complete denture wearers. J Prosthet Dent 1972; 27:
120-32.

14

Orthlieb JD, Laurent M, Laplanche O. Cephalometric estimation of vertical dimension of occlusion. J Oral Rehabil 2000; 27:
802-7.

15

McCord JF, Grant AA. Registration: stage II intermaxillary

relations. Br Dent J 2000; 188: 601-06.

16

Silverman, Meyer M. The speaking method in measuring the

vertical dimension.J Prosthet Dent 2001; 85: 427-31.

17

Toolson LB, Smith DE. Clinical measurement and evaluation of

vertical dimension. J Prosthet Dent 2006; 95: 335-39.

From the results of the present study it was concluded that with the use of lateral cephalographs one
can evaluate the vertical dimension of edentulous
patients in Pakistani population. This method is an
additional method that is inexpensive, simple and
complementary to the conventional methods used to
evaluate the vertical dimension. The same vertical
dimension may also be used for future prosthetic
reconstruction.
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