Biomechanical Considerations in the

Management of the Vertical Dimension

Stanley Braun

The vertical dimension may be altered purposefully or unintentionally dur-

ing therapy by dental extrusion, intrusion, growth modification, or orthog-
nathic surgery. Vertical changes result in the mandible rotating either open
or closed with corresponding alterations in interarch dental relationships,
facial esthetics, and lip and tongue function. The biomechanics involved in
the treatment of patients who exhibit an anterior open bite or a deep
overbite related to excessive or deficient vertical facial dimensions are
discussed. (Semin Orthod 2002;8:149-154.) Copyright 2002, Elsevier
Science (USA). All rights reserved.

he vertical dimension has been defined by it tends to drive the dental occlusion toward a
T some l-:~ as the relationship between the
Frankfort and mandibular planes and by others 4-7
Class III relation. If, however, the t r e a t m e n t ob-
jective requires b o t h the maxillary and mandib-
as the relative relationship between the anterior ular dentitions to be positioned m o r e forward,
and posterior facial heights. Alterations in the the dentomaxillary complex may also be posi-
vertical dimension can occur purposefully or un- tioned anteriorly during the surgical impaction
intentionally during therapy by dental extrusion, process. Thus, it is possible that either one or
intrusion, growth modification, or surgical inter- b o t h jaws may require surgical p r o c e d u r e s de-
vention. Vertical changes result in the mandible p e n d i n g on the p r e t r e a t m e n t facial objectives
rotating either open or closed with corresponding established. It should be n o t e d that postsurgical
alterations in interarch dental relationships, facial vertical growth has b e e n reported; therefore,
esthetics, and lip and tongue function. This article timing of surgery is vital? °,~
examines the biomechanics involved in the treat- In a patient u n d e r g o i n g circumpubertal skel-
ment of patients who exhibit an anterior open bite etal growth, it is possible to alter the vertical
or a deep overbite related to excessive or deficient c o m p o n e n t of maxillary growth through the use
vertical facial dimensions. of extraoral orthopedic forces. In Figure 1, a
high-pull h e a d g e a r is shown; it's force is directed
The Anterior Open Bite Related to an through the center of resistance of the den-
Excessive Vertical D i m e n s i o n tomaxillary c o m p l e x ) 2,13 It should be n o t e d that
tile direction (angle) of the h e a d g e a r force is
This may be treated by surgically impacting the designed to p r o d u c e a larger maxillary intrusive
dentomaxillary complex. As a consequence, the c o m p o n e n t than a distally directed one. By re-
mandible will rotate, contributing to a reduction stricting the vertical c o m p o n e n t of maxillary
of the vertical dimension, s,~-~Ancillary mandibu-
growth in this m a n n e r , the n o r m a l vertical com-
lar surgery may be required d e p e n d i n g on the
p o n e n t of m a n d i b u l a r growth may also be
resultant degree of m a n d i b u l a r rotation because
masked through m a n d i b u l a r rotation. This com-
bined effect reduces the vertical dimension.
T h e line of action of the h e a d g e a r force may
From Vanderbilt University Medical Center; Nashville, TN. alternatively be positioned distal to or anterior
Address corresponde*we to Stanley Brzlun, DDS, MME, 7940 to the center of resistance of the dentomaxillary
Dean Road, Indianapolis, IN 46240.
Copyright 2002, Elsevier Science (USA). All rights rescinded.
complex (Fig 2). This would tend to rotate the
1073-8746/02/0803 0006535.00/0 dentomaxillary c o m p l e x during growth about a
doi: 10. 1053/sodo. 2002.125434 point anterior or posterior to its center of resis-

Seminars in Ot¢hodontics, Vol 8, No 3 (September), 2002: pp 149-154 149

150 Stanley Brau,z

More recently, simultaneous high-pull headgear in

combination with a bite block have been used in
the reduction of vertical excesses. 17
If extractions are required in a patient with an
excessive vertical dimension, the biomechanics of
extraction-site closure must be carefully controlled
to avoid eruption of the posterior teeth. One com-
monly used method of extraction-site closure is to
use horizontal chains or coil springs while the
teeth are engaged on a relatively light archwire.
This does not apply defined moment-to-force ra-
(~ Dentomaxlllary tios (M/F) to the teeth anterior and posterior to
Center of Reslsitance
the extraction site(s). For teeth to translate, a con-
sistent M / F approximating 10:1 is required. This
cannot be provided by chains a n d / o r coil springs
Figure 1. High-pull headgear force through the den- while the teeth are engaged on an archwire. ~8-zl In
tommxillmy complex center of resistance.
this approach to the closure of extraction site(s),
tile anterior and posterior teeth characteristically
tance, d e p e n d i n g on the point of application of tip into the extraction site(s) during closure. The
the headgear force relative to its center of resis- M / F ratios are less than 10:1. Consequently, sec-
tance.l:~ Rotation of the dentomaxillary complex ondary reverse curve of Spee archwires are then
in this m a n n e r may be desirable if it is initially introduced with the concept that two equal and
abnormally angulated so as to produce an in- opposite moments will be produced to upright the
creased vertical dimension. The extraoral forces tipped teeth. These uprighting moments must be
of the headgear may also produce some dentoal- equal and should be in the range of 3,000 gr.mm
veolar response while altering the growth of the each for et~cient root movement with minimal
dentomaxillary complex because the forces are root resorption, m This is seldom the case, and
applied through the dentition.
Functional appliances with bite blocks have
been used to diminish the eruption of the poste- ~ ;
rior teeth and the vertical growth component of
the dentomaxillary complex. 1<15 If the bite regis-
tration is designed to bring the mandible forward, d
then a headgear effect is obtained wherein the ~¢~ P
anteroposterior growth component of the den- act
tomaxillary complex may also be diminished56

Center of ResisRanee
=

Figure 3. Moments and vertical ff)rces resuhing from

Figure 2. High-pull headgear forces anterior or pos- placement of reverse cmwe of Spee archwires after
terior to the dentomaxillary center of resistance, extraction-site closure.
 Management of the Vertical Dimension 151

when there is an inequality of uprighting mo- (Fig 4). Any constrained body (a moth, a group of
ments, vertical forces occur, resulting in the poten- teeth, or an osseous structure joined to other os-
tial eruption of the posterior teeth. The spring rate seous structures through viable sutures) will react
primarily varies inversely as the cube of the inter- to the forces applied to it relative to its center of
bracket wire length across the extraction site(s) (R resistance, z6,27 The locations of the centers of re-
c~ 1/L~). Thus, the rate is high, and the anterior sistance of the dentomaxillary complex have re-
and posterior moments easily become unequal be- cently been determined. 12 They are located on a
cause the posterior and anterior tooth movement line drawn perpendicular to the functional occlu-
velocities are not necessarily equal. When the pos- sal plane (FOP) through the distal contacts of the
terior m o m e n t exceeds the anterior moment, an maxillary first molars as seen in a sagittal cephalo-
undesirable eruptive force will occur (Fig 3). This gram. They are further identified on the afore-
is undesirable in the patient already exhibiting an mentioned perpendicular line at one half the dis-
increased vertical dimension. The same problem tance from the FOP to a line drawn parallel to tile
also exists with the placement of archwire V bends FOP through the inferior border of the orbit.
at the extraction site(s) related to closure. Again, There are two centers of resistance of the den-
the applied moments must be equal throughout tomaxillary complex when reviewed in the frontal
the range of activation, and because this approach aspect. This is because tile dentomaxillary com-
invariably involves a high spring rate, it makes plex is essentially made up of two bones, a right
inequalities in the moments applied to the ante- and a left maxilla each containing one half the
rior and posterior teeth a likely occurrence as the dental arch. Each maxillary bone articulates with
anterior and posterior teeth approach each other. the other at the median palatine suture and rela-
To reduce this problem, frequent in-office appli- tively symmetrically on each side with the fron-
ance adjustments are required. One should also tomaxillary suture, tile nasomaxillary suture, the
consider that the increased angulation of the arch- zygomadcomaxillary suture, and the transverse
wire at the brackets' interfaces might result in palatine suture. Because each of the protraction
significant undesirable frictional effects. forces (one on each side) results in a m o m e n t that
A controlled, efficient means of extraction- tends to stress the midpalatine suture greater at its
site closure has been outlined previously ts-2° distal area than at its anterior area, each half of the
wherein m o m e n t alterations along with related dentomaxillary complex acts somewhat indepen-
vertical forces between the anterior and poste- den@. Thus, two centers of resistance are identi-
rior teeth are u n d e r control of the orthodontist fied. However, if protractive forces are applied in
t h r o u g h o u t extraction-site closure. It should be the presence of a stiff 0.036-in stainless steel trans-
noted that in the most stringent requirement palatal arch or a sutural expander, the left and
wherein the entirety of the extraction site(s)
must be occupied by the anterior teeth a maxi-
m u m vertical eruptive force of 22.7 g is pro-
duced at the occlusal surfaces of the six poste-
rior teeth. 18 Functional (biting) forces easily
negate this vertical force preventing their erup-
tion. This is true for the patient with a steep
mandibular plane angle as well. 21
It has been suggested that extractions be con-
sidered for the purpose of protracting the pos-
terior teeth into the extraction sites, thereby
reducing the vertical dimension, z2,93 Recent
studies do not substantiate this. z4,25
A maxillmy protraction device commonly used O= Oentomaxillary center of resistance

in the treatment of Class III malocclusions consists F = Protraction force applied to teeth
F' = F = Protraction force equivalent at center of resistance
of bilateral forces emanating from a face mask and M = F(Y) = Tipping moment at center of resistance
applied to the first molar or canine regions. The FOP = Functional occlusal plane
F(sin O) = Eruptive component of protraction force
occlusogingival angle of the protraction forces in
the sagittal view is determined by the commissure Figure 4. The force system produced by a commonly
of the lips and the intraoral points of attachment used protraction device.
152 Stanley Braun

ration of the dentomaxillary complex is eliminated

or significantly reduced. However, an undesirable
eruptive component of the protraction force re-
mains, which results in an increased vertical di-
mension with the consequences of mandibular ro-
tation and a decreased overbite. For true
protraction to occur, the line of action of any
protractive forces must pass through the centers of
resistance of the dentomaxillary complex and be
parallel to the occlusal plane.
Recently, a protraction device design has
been reported that permits true protraction
forces to be applied through the centers of re-
sistance of the dentomaxillary complex? :4 This
consists of a standard facebow c o n t o u r e d to in-
sert in the maxillary molar tubes from the distal
(Fig 6). The outer bow may be adjusted so that
the lines of action of the protraction forces pass
through the centers of resistance bilaterally as
shown in Figure 7, resulting in true protraction
(translation) of the dentomaxillary complex. It
is important to note that in the case of vertical
maxillary excess the outer bow can be adjusted
to have an intrusive (impaction) component. An
extrusive c o m p o n e n t can be similarly obtained
Figure 5. Protraction tbrce adjusted to pass through
the centers of resistance of the dentomaxillary com- in the case of a maxillary vertical deficiency. The
plex bilaterally. protractive forces may also be located superior
to the center of resistance (in the sagittal view),
resulting in a clockwise m o m e n t accompanying
right maxillary bones act as one for the separating the protractive force. This resulting m o m e n t has
moments are negated by the presence of either of the potential of rotating the anterior portion of
these devices or their equivalent. In the sagittal the maxilla downward without posterior maxil-
view, only one center of resistance is identified lary extrusion. Thus, it may be possible to obtain
since the two are superimposed. Consequently, the an improved incisor/lip relationship if desired.
"aforementioned protraction forces (attached to As a result, any alterations in the vertical dimen-
either the molar or canine regions near the plane sion, purposeful or n o n e at all, are u n d e r the
of occlusion and forced to exit through the com- clinician's control.
misure of the lips) will cause a counterclockwise
m o m e n t and eruptive forces relative to the centers
The Deep Overbite Related to a
of resistance of the dentomaxillary complex (in
Deficient Vertical Dimension
the sagittal view). As a result, the dentomaxillary
complex will rotate about a point close to its cen- In a growing individual, the mandible may be
ters of resistance.a9 It is therefore important for the rotated open by supereruption of the mandibu-
clinician to reco~fize that this type of protraction
device does not cause protraction. It causes den-
tomaxillary rotation, which results in an increased
lower facial height and a decrease in the upper
facial heightY 6 In a recent thesis, z7 it has been
shown that if the points of protraction force attach-
ments are relatively high in the canine vestibular
regions, their lines of action pass through, or ex-
tremely close to, the centers of rotation of the Figure 6. Inner bow of a protraction hcadgear in-
dentomaxillary complex (Fig 5). Consequently, ro- serted from the distal of the molar headgear tubes.
 Management of the Ve,¢ical Dimension 153

permitting the posterior teeth to passively erupt.

T h e bite plate should be in place continuously as
well as after the eruption of the m a n d i b u l a r
posterior teeth to allow m a n d i b u l a r growth to
catch up. High-pull h e a d g e a r to the d e n t o m a x -
illary c o m p l e x to reduce its eruption and to
c o m p e n s a t e for the resultant m a n d i b u l a r rota-
tion, which tends to drive the dentition in a Class
II direction, should be considered.
If posterior dental eruption is used to reduce
a d e e p overbite, to increase the m a n d i b u l a r
plane angle, and to increase anterior facial
height in the nongrowing patient or in a patient
with limited dentofacial growth, c o m p e n s a t o r y
m a n d i b u l a r orthognathic surgery or distraction
osteogenesis to alter the ramal a n d / o r body
length of the mandible is necessary. 3°,3~
T h e lower facial height may also be increased
in the growing individual t h r o u g h encourage-
m e n t of vertical growth and dental eruption of
the maxillary complex. This may be accom-
plished with cervical headgear. Its orthopedic
forces may be t h r o u g h the center of resistance of
the dentomaxillary complex (Fig 8) or anterior
or posterior to it, d e p e n d i n g on the type of
alteration desired in the C axis. :~ T h e accompa-
Figure 7. Line of action of protraction force passing nying downward m a n d i b u l a r "rotation" that oc-
through the center of resistance of the dentomaxilla W curs tends to alter the occlusion in a Class II
complex, resulting in translation. direction. T h e distal c o m p o n e n t of the cervical
headgear, a c c o m p a n i e d by m a n d i b u l a r growth,
lar posterior teeth when using reverse curve of is n e e d e d to reduce this transient effect.
Spee mechanics. This will result in a reduction Over time, interarch elastics will, in the case
of a deep overbite while increasing the mandib- of a Class III traction, cause eruption of the
ular plane angle, the anterior facial height, and maxillary posterior teeth and in the case of a
facial convexity. This a p p r o a c h often requires
ancillary growth modification of the dentomax-
illary complex with high distal pull headgear.
Failing this, the Angle Class II tendency created
by rotating the mandible o p e n may not be cor-
rected through growth alone. Additionally, fail-
ure to alter the continued downward and for-
ward growth of the dentomaxillary complex may
result in an undesirable anterior facial height. 2°
To avoid m a n d i b u l a r incisor flaring, which ac-
companies reverse curve of Spee mechanics, the
clinician should consider using s e g m e n t e d arch
~) Dentomaxillary
mechanics, wherein the clinician determines the Center of Resistance
location of the occlusal plane rather than the
appliance, l s,90,m.28,29
Passive eruption of the m a n d i b u l a r posterior
teeth may also be e n c o u r a g e d t h r o u g h the use of Figure 8. Potential lines of action of cervical head-
a bite plate. This tends to prevent the normal gear forces relative to the center of resistance of the
eruption of the m a n d i b u l a r anterior teeth while dentomaxillary complex.
154 Stanley Braun

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