A Newly Proposed Method to Predict Optimum Occlusal

Vertical Dimension
Shuichiro Yamashita, DDS, PhD,1 Mariko Shimizu, DDS,2 & Hidenori Katada, DDS, PhD3
1

Professor, Department of Clinical Oral Health Science, Tokyo Dental College, Tokyo, Japan
Postgraduate Clinical Assistant, Suidobashi Hospital, Tokyo Dental College, Tokyo, Japan
3
Lecturer, Department of Orthodontics, Tokyo Dental College, Tokyo, Japan
2

Keywords
occlusal vertical dimension; lower facial
height; cephalometric analysis; multiple linear
regression analysis; prediction formula.
Correspondence
Shuichiro Yamashita, Department of Clinical
Oral Health Science, Tokyo Dental College,
2-9-18 Misakicho, Chiyoda, Tokyo 101-0061,
Japan. E-mail: syamashita@tdc.ac.jp
The authors deny any conflicts of interest.
Accepted April 15, 2014
doi: 10.1111/jopr.12223

Abstract
Purpose: Establishing the optimum occlusal vertical dimension (OVD) in prosthetic
treatment is an important clinical procedure. No methods are considered to be scientifically accurate in determining the reduced OVD in patients with missing posterior
teeth. The purpose of this study was to derive a new formula to predict the lower facial
height (LFH) using cephalometric analysis.
Materials and Methods: Fifty-eight lateral cephalometric radiographs of Japanese
clinical residents (mean age, 28.6 years) with complete natural dentition were used
for this study. Conventional skeletal landmarks were traced. Not only the LFH, but six
angular parameters and four linear parameters, which did not vary with reduced OVD,
were selected. Multiple linear regression analysis with a stepwise forward approach
was used to develop a prediction formula for the LFH using other measured parameters
as independent variables.
Results: The LFH was significantly correlated with Gonial angle, SNA, N-S, GoMe, Nasal floor to FH, Nasal floor to SN, and FH to SN. By stepwise multiple linear
regression analysis, the following formula was obtained: LFH (degree) = 65.38 +
0.30* (Gonial angle; degree) 0.49* (SNA; degree) 0.41* (N-S; mm) + 0.21*
(Go-Me; mm) 15.45* (Nasal floor to FH; degree) + 15.22* (Nasal floor to SN;
degree) 15.40* (FH to SN; degree).
Conclusions: Within the limitations of this study for one racial group, our prediction
formula is valid in every LFH range (37 to 59), and it may also be applicable to
patients in whom the LFH deviated greatly from the average.

Adequate posterior occlusal support is required to maintain

healthy stomatognathic function. Loss of posterior teeth may
result in neuromuscular instability of the mandible, reduced
masticatory efficiency, and loss of occlusal vertical dimension
(OVD).1 In such cases, oral rehabilitation would be needed
to restore the reduced OVD and posterior occlusal collapse.
Establishing the optimum OVD in prosthetic treatment is
an important clinical procedure. Although various methods
have been described, establishing an appropriate OVD remains
challenging.2,3 A number of prosthetic considerations are involved, such as analysis of the existing occlusion and occlusal
plane, availability of freeway space, size and location of edentulous areas, number, position, and condition of the teeth in each
arch, and the need for improving esthetics. Proper evaluation
of the OVD in the original occlusal condition and an appropriate treatment plan are essential, and this fact motivated us to
develop an effective method for diagnosing reduced OVD.
Usually in the initial stages of treatment, interim prostheses
are fabricated for immediate reestablishment of function and

esthetics (Fig 1). The interim prostheses are useful to reestablish the patients correct OVD before installation of the definitive prostheses. This is a simple, noninvasive, and totally reversible procedure that allows reestablishment of the patients
immediate functional and esthetic concerns.4 The new OVD is
commonly obtained from a range of physiologic, metric, phonetic, and esthetic methods to favor prosthetic planning. As
already mentioned above, although various methods for determining OVD have been described, many of the proposed
techniques have been adapted from complete denture fabrication procedures.5 None have been assessed to be scientifically
more accurate than another in determining the reduced OVD in
patients with missing posterior teeth. Therefore, to improve the
accuracy of the recording procedure, a trial-and-error method
using more than one procedure is most commonly employed
currently.
The OVD has been defined as the distance measured between two points when the occluding members are in contact.6
The reference points found on soft tissues are not stable and

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 287290 

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Prediction of Occlusal Vertical Dimension

Yamashita et al

Figure 2 LFH is the angle formed by the intersection of two lines, ANSXI and XI-PM.

Figure 1 (A) Initial clinical aspect, showing the loss of OVD caused
by severe wear of teeth and posterior occlusal collapse. (B) Interim
prostheses are fabricated for the immediate reestablishment of function
and esthetics.

definite; therefore, bone reference points are useful to increase

the accuracy of the measurements. Determination of individual
and morphological indices of OVD using cephalometric analysis may represent one of the ways to identify better solutions
in planning the artificial occlusion complex. The lower facial
height (LFH) is thought to be an important angular value in
cephalometric analysis, which illustrates OVD problems. This
is the angle formed by the intersection of two lines, ANS-XI and
XI-PM (Fig 2). The LFH does not usually change significantly
with age, and the norm is 47, with a clinical deviation of 4.7
However, it will be difficult to apply a fixed average value to all
patients with reduced OVD in prosthetic treatment. It may be
more practical to compute the value for each patient. Therefore,
the purpose of this study was to derive a new formula to predict
the LFH using linear and angular parameters in cephalometric
analysis. We hypothesized that the newly developed formula
to calculate the LFH illustrated the OVD more accurately than
using the mean value of LFH.

Materials and methods

Welfare. These lateral cephalometric radiographs were selected

from the files of the Orthodontic Department of Tokyo Dental
College Suidobashi Hospital, which were taken by the residents
themselves as part of their orthodontic training. The participants
consisted of 25 men and 33 women, aged 25 to 40 years (mean
age, 28.6 years). The exclusion criteria were: (1) individuals
undergoing dental treatment; (2) individuals with missing teeth
(except third molars/wisdom teeth); (3) individuals with a history of orthodontic treatment; (4) individuals with subjective
symptoms of temporomandibular disorders; and (5) individuals with a history of systemic disease at the time of history
taking. The study protocol was approved by the Ethics Committee of Tokyo Dental University (#308). The radiographs were
converted into digital form for computer processing.
Cephalometric measurement

Conventional skeletal landmarks were traced manually by one

author on a personal computer (Endeavor NJ5500E; Epson Corporation, Nagano, Japan). Cephalometric analysis was done
using computer software (WinCeph ver.9; Rise Corporation,
Miyagi, Japan). Not only the LFH, but six angular parameters
and four linear parameters, which did not change with reduced
OVD, were selected and measured (FH to SN, SNA, Nasal floor
to SN, Nasal floor to FH, Gonial angle, Cranial deflection, N-S,
N-ANS, N-PNS, and Go-Me). To determine the reliability of
the method, all radiographs were retraced and remeasured by
the same examiners at an interval of approximately 2 weeks. A
paired t-test was used for each parameter to compare the two
measurements. No significant difference was found between
the measurements.

Cephalometric radiographs

The study material consisted of 58 lateral cephalometric radiographs of Japanese clinical residents with complete natural
dentition in centric occlusion. Residents are trainees enrolled
in programs designated by the Minister of Health, Labour and
288

Statistical analysis

The Pearsons correlation coefficient was used to assess correlations between the LFH and other parameters. Multiple linear
regression analysis with a stepwise forward approach was used

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 287290 

Yamashita et al

Prediction of Occlusal Vertical Dimension

between measured and predicted LFH was 2.1 with a standard

deviation of 1.3.

Discussion

Figure 3 Predicted LFH plotted against measured LFH for all participants.

to develop a prediction formula for the LFH using other measured parameters as independent variables. All statistical data
were analyzed using statistical software (SPSS 12.0; SPSS Inc.,
Chicago, IL). A p-value of <0.05 was considered statistically
significant.

Results
The cephalometric measurements are listed in Table 1. The
mean value of LFH was 47.9 with a standard deviation of
4.0. The mean values of LFH for men and women were
47.1 and 48.6, respectively. No significant difference was
observed between men and women (Students t-test; p =
0.16).
The LFH was significantly correlated with Gonial angle (r =
0.60), SNA (r = 0.53), N-S (r = 0.39), Go-Me (r = 0.33),
Nasal floor to FH (r = 0.28), Nasal floor to SN (r = 0.28), and
FH to SN (r = 0.28). Using stepwise multiple linear regression,
the following formula best predicted the LFH:
LFH (degree) = 65.38 + 0.30* (Gonial angle; degree)
0.49* (SNA; degree) 0.41* (N-S; mm) + 0.21* (Go-Me;
mm) 15.45* (Nasal floor to FH; degree) + 15.22* (Nasal
floor to SN; degree) 15.40* (FH to SN; degree); (r2 = 0.61).
Figure 3 shows the relationship between the measured and
predicted LFH by this formula. The mean value of difference

To our knowledge, this is the first study to measure the LFH

in healthy Japanese adults aged 25 to 40 years. In this study,
there was no significance sex difference in the mean value of
the LFH. Therefore, the cephalometric measurements of men
and women were not analyzed separately.
The mean value of the LFH was 47.9 with a standard deviation of 4.0, which was in agreement with the value reported
by Ricketts et al7 However, the value ranged widely from 37
to 59. The same tendency was shown in the study by Orthlieb
et al:8 the LFH ranged from 30 to 64 in 227 men and 278
women with a mean age of 31.01 years. As mentioned in the
introduction, it was difficult to average all the patients based
on these results. The value for each patient should be clinically
computed.
Of the 10 angular and linear parameters that did not easily vary with reduced OVD, Gonial angle, SNA, N-S, Go-Me,
Nasal floor to FH, Nasal floor to SN, and FH to SN were significantly correlated with LFH. The Gonial angle versus the
LFH showed the highest coefficient of correlation, and this angular parameter may be an important variable for determining
the LFH. The Gonial angle has been thought to correlate with
both function and shape of the muscles of mastication.9 Because the masseter and medial pterygoid muscles insert into
the region of the Gonial angle, the contractile power of these
muscles also influences the shape of the mandibular base. Electromyographic investigations have shown that strong masseter
and anterior temporal muscle activity correlate with small anterofacial height and small Gonial angle.10,11
Orthlieb et al8 stated that ideal OVD using the regression
formula was more interesting than the mean value, because
it was more specifically related to the patient; however, they
also stated that distribution was wide (r2 = 0.478), and their
result was insufficient to claim a very accurate measure of
the OVD. One possible explanation of the dispersion could be
that they used simple regression, unlike this study. To evaluate
OVD, they proposed a pluralistic method of calculation using
several regression formulae to compensate for the inaccuracy on
comparison with several estimations. Therefore, the prediction
formula derived in this study was based on multiple regression
using seven cephalometric parameters.
The mean difference between the measured and predicted
LFH values was 2.1. Thus, our prediction formula is valid in

Table 1 Mean values, standard deviations, minimum values, and maximum values of cephalometric measurements
LFH
FH to
SNA
Nasal floor to Nasal floor
Gonial
Cranial
NNNGo(degree) SN (degree) (degree) to SN (degree) FH (degree) angle (degree) deflection (degree) S (mm) ANS (mm) PNS (mm) Me (mm)
Mean
SD
Minimum
Maximum

47.9
4.0
37.3
58.7

6.9
2.9
0.5
12.7

82.1
3.8
73
89.8

8.7
3.9
2.7
26.8

1.8
3.8
6.5
14.2

123.6
6.8
105.4
140.3

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 287290 

26.2
2.7
19.7
31.3

71.5
3.4
61.9
80.1

59.4
4.2
47.5
68.8

75.2
3.9
67.6
84.6

77.0
5.5
65.3
93.7

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Prediction of Occlusal Vertical Dimension

Yamashita et al

every LFH range (37 to 59), and the prediction formula may
also be applicable to patients in whom the LFH deviated from
the average value greatly. This study supports the hypotheses
that the newly developed formula to calculate the LFH illustrates the OVD more accurately than using the mean value of
LFH.
Several important limitations of this study should be noted,
and some methodological issues require mention. First, because the subjects were limited to a single race (i.e., Japanese),
and they may have been too young (28.6 years) to be used as
fundamental data for patients with reduced OVD. It will be necessary to gather patients from broader age and racial groups.
Second, if reduced OVD with asymmetric posterior occlusal
collapse has been neglected for a long time, it is likely that
the values of selected cephalometric parameters are influenced
during further precise analysis. In such cases, both lateral and
frontal cephalometric analysis may be needed as well. Therefore, further analysis is required to improve the accuracy of the
predicted LFH.

Conclusion
The following conclusions were derived regarding the LFH in
58 Japanese clinical residents with complete natural dentition.
The LFH was significantly correlated with Gonial angle, SNA,
N-S, Go-Me, Nasal floor to FH, Nasal floor to SN, and FH to SN.
By stepwise multiple linear regression analysis, the following
formula was obtained: LFH (degree) = 65.38 + 0.30* (Gonial
angle; degree) 0.49* (SNA; degree) 0.41* (N-S; mm) +
0.21* (Go-Me; mm) 15.45* (Nasal floor to FH; degree) +
15.22* (Nasal floor to SN; degree) 15.40* (FH to SN; degree).
Within the limitations of this study for one racial group, our
prediction formula is valid in every LFH range (37 to 59),
and it may be applicable to patients in whom the LFH greatly
deviated from average value.

290

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Journal of Prosthodontics 24 (2015) 287290 

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