Basic Principles to Find Lost Vertical Dimension for Full-Mouth and Implant Rehabilitation
OVERVIEW
In this article and case study, Dr. Anthony LaVacca applies Dr. Earl Pound's guidelines for finding the vertical dimension of occlusion. A photo essay illustrates the case of a woman who sought full-mouth rehabilitation in hopes of looking younger. The video and an animation demonstrate the techniques advocated in Dr. LaVacca's article.
Anthony LaVacca, DMD DMD/Prosthodontist/Owner, Naperville Dental Specialists & General Oral Health Care
Naperville, IL
630-848-2010 alavacca@aol.com
Dr. Anthony LaVacca is a graduate of Temple University Kornberg School of Dentistry. He has served as director of the General Practice Residency program and as interim director of the postgraduate program in prosthodontics at Montefiore Medical Center/Albert Einstein College of Medicine, where he is an assistant professor. Dr. LaVacca is a member of the American College of Prosthodontists, ADA, AO and International Association for Dental Research. He has lectured internationally on implant-related topics.
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When "s" sounds are being enunciated at conversational speed, the mandible moves to the most forward and upward (closed) position it ever assumes during speech, wrote Dr. Earl Pound. This position can be used to establish the vertical dimension of speech and clarity of the "s" sounds.
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One of the most common questions that arises with larger cases is: Where is the vertical dimension? How did you find the vertical dimension? How did you transfer the vertical dimension to the final prosthesis? It seems like all of us struggle with this concept, and we try to use a significant amount of classic laboratory information to fit our patients into a generic tooth set-up. But all our patients are not the same. In this article, I will present principles from a classic article by Dr. Earl Pound, "Let 'S' Be Your Guide,"1 to help you determine where the correct vertical dimension is located. This technique may help you, as it did me, to find where a true vertical dimension is and how it relates to your full-mouth rehabilitations, implant rehabilitations, denture cases and cosmetic dentistry patients. You can read a similar article by Dr. Pound, "The Vertical Dimension of Speech: The Pilot of Occlusion."
I have a study club in Naperville, Ill., where my practice is located. Basically, it's a group of doctors who get together on a monthly basis to review some of the problems that arise in our practices. During our discussions, we describe the complications encountered during the past month and work together to resolve them.
Routinely, when I conduct lectures about vertical dimension, I ask the question, "Who here likes to treat full-mouth rehabilitations?" If I have an audience of 100, I'll see 30 or 40 hands go up. Then I lead into, "Who likes to treat veneers?" Every hand in the audience goes up. Then I throw a little curveball and ask, "Who really likes to fabricate dentures?" Literally, four or five hands out of 100 will go up. It's really interesting that no one likes to do dentures anymore, yet the foundation for our full-mouth rehabilitations and many of our cosmetic veneer cases is developed from basic denture principles.
Sometimes upper and lower full dentures are the hardest full-mouth rehabilitation cases to treat, unless we have implants in place. Dentures allow patients who are edentulous to have teeth, smile and have a feeling that they are whole again. Can you imagine what it is like to have dentures? But dentures also need to be functional, and so do our full-mouth rehabilitation and veneer cases. Sometimes we get caught up in the esthetic component of our cases and forget about the functional part. One of the key functional parts is vertical dimension and occlusion. When you're starting from nothing, meaning you have two edentulous arches, and maybe the case was referred to you (the restorative doctor), and you have no teeth to guide you, no diagnostic casts, no wax-up, you need to find a starting point. Or your patient comes in with dentures and his or her face looks terrible. The solid starting points to help you treat your patient come from our basic denture principles.
Using these solid denture principles, we can take a patient who comes in with significant advanced periodontal disease, as demonstrated in Figure 1, and bring her back to a youthful appearance, as demonstrated in Figure 2, by providing proper facial esthetics and tooth position for a smile that is harmonious with the patient's face.
Proper facial esthetics and tooth position must be built within the boundaries of the patient's vertical dimension and occlusion. When treating large implant reconstructive cases, the question always becomes: How did you do that? Did you treat the patient with five implants, 10 implants? The number of implants doesn't really matter. It's actually the positioning and length of the abutments that establishes resistance and retention form of your prosthesis (Fig. 3).
If we are replacing hard and soft tissue on implants, it's critical to understand where the vertical dimension is and how to find that position, because that is going to be our starting point for developing esthetics and function.
When the vertical component is over-closed, the typical result is a Class III or "witch's chin." This usually leads to poor facial esthetics and lack of lip support. But this is only the esthetic component. Functionally, it is difficult to chew because the occlusal plane is low, making it difficult to bring the food back onto the plane due to its lower position. The patient also needs to be able to speak properly and smile in a way that is attractive and complements his or her facial characteristics.
For patients who have been edentulous for a considerable amount of time and have lost a significant amount of bone, one of our concerns within the vertical component is the loss of gingival tissue and the alveolus. If we are replacing the gingival tissue, the alveolus and the teeth, it's critical to know where this vertical position is when we're designing our substructure. These cases become significantly expensive in the laboratory if we don't have the vertical properly set along with the proper tooth position.
So what does it matter? The vertical component will allow us to make the patient's teeth within the muscular component and within the physiological component of his or her musculature, lip support and speech. That will give us a final result that is proper in form, function and esthetics. The patient in Figure 4 demonstrates several basic denture principles. The mandibular tooth plane bisects the corners of his mouth. His smile line follows the lower lip. If you could hear him speak, he would be able to demonstrate how his sibilant sounds function within the arena of his maxillary-mandibular rehabilitation. We would know that his fricative sounds are something that we are going to utilize to establish maxillary anterior tooth length. But, once again, all of these factors need to function within the muscular realm of our patient for a successful functional and esthetic result.
Now let's take a look at real life. In Figure 5, we have a midline that properly divides the face through the center of the nose and the lips. A horizontal line can be drawn through the pupils. Two additional parallel lines can be drawn to break the face into thirds.
In Figure 6, we have a patient whose interpupillary line is even. If we look at her face for vertical symmetry, we see that it is divided into equal halves. One of the things that really jumps out with this patient, however, is that her lower third is significantly larger than her middle third. This makes her look, as she stated, like a witch or very old.
What the patient really wants is to look young again. She wants to look the way she did when she was 20-some-odd years old. We have all encountered this type of patient. When we look at our patient from a lateral view (Fig. 7), you can really see that the lower third is exacerbated. One of the things with the lower third being exacerbated is, if we take a closer look with the closed vertical dimension, you'll notice a significant number of lines or wrinkles in her mid-face (Fig. 8). You would never want to tell a female patient that her lips look wrinkly, but this patient demonstrates an overclosed vertical dimension and subsequent deepening of the nasolabial folds. With this also comes a loss of the vermilion border or an inversion of the wet-dry line. When we retract her lips, we can see the reason for the above characteristics and the related prosthesis (Fig. 9).
When a patient has had a denture for many years, we have a loss of bone in the maxilla, a loss of bone in the mandible and a significant loss of vertical dimension, or supposed loss of vertical dimension. We have to get back to our starting point. Why would we want to follow traditional laboratory denture guidelines and set the teeth over the ridge after there has been a significant amount of bone loss?
It really doesn't make sense. If we're going to set teeth over the ridge and the bone has resorbed, are we setting the teeth in the right position? And if we do this, will it make our patient look old?
The panoramic view in Figure 10 demonstrates the patient before implant placement. You can see how much bone loss she's had over the years. How do I know she's had a significant amount of bone loss? We had the mental nerve sitting on the crest of the ridge and the maxillary arch is severely atrophic.
The patient's primary goal is to look younger. So she had five implants placed in the mandible (Fig. 11). Why the mandible? Stabilizing the mandibular denture allows us to increase the vertical dimension and bring the maxillary and mandibular teeth forward to fill out the midface, developing superior esthetics. How, you may ask? Stabilizing the mandibular denture with implants also removes the ability of the muscular component to lift the denture while the patient performs normal actions. In summary, with the prosthesis now anchored, we can bring the teeth forward, past the crest of the ridge on the mandible, allowing us to bring our patient's maxillary teeth past the crest of the ridge, creating a fuller, more esthetic look and enabling our patient to smile with confidence.
Our patient presented to an oral surgeon and had implants placed in the hopes of achieving a more youthful appearance. But with the way the initial dentures were constructed "over the ridge," with a significant loss of vertical dimension, they made her look old. She was not happy.
Figure 12 shows the final result, which made the patient happy and met her expectations. To achieve your patient's desired result, I advise conducting an interview to develop a rapport to determine your patient's expectations prior to treatment.
Have the patient bring in pictures and photographs of when they were younger, of how they looked, how their teeth looked. The end result that really made this patient happy was restoring her smile — filling out her smile and making her look youthful again. I knew from the start I would be successful with her treatment because of all the deficiencies with her previous prosthesis.
When I look at our patient, one of the things I see is an older woman who takes good care of herself. How do I recognize that? She goes to the beautician frequently; she colors her hair; she manicures her eyebrows. What's interesting about her eyebrows is she manicures them so they are higher and thinner than her existing eyebrows, which gives her eyes a brighter, more youthful appearance. She also wears mascara and lip liner. Lip liner is especially important to create the illusion of larger lips. By lining the lips up over their natural border, it gives them a fuller look. When our patient presented to me, as seen in Figure 6, she was very unhappy with the way her dentures looked. She showed me pictures and demonstrated to me how she routinely looks and wants to look, so we were able to find her vertical dimension. We worked on esthetics, tooth size, shape and color from her pictures and from her diagnostic information, and then we gave her back her smile.
Now, I'll explain how this was achieved. I transferred her denture information to the master cast. By utilizing the incisal papilla as a stable point, I was able to measure from the distal aspect of the incisal papilla to the incisal edge of the old denture. This demonstrates the incisal edge tooth position is 9 mm from the incisal papilla. For the new denture, I took the position from the incisal papilla and measured the same way and had a total distance of 13 mm (Fig. 13). What will this do for our patient facially? It begins to unfold and rejuvenate the maxillary mid-face by reducing wrinkles on her maxillary lip.
Subsequently, it will fill out the nasolabial folds and give our patient a more youthful appearance. Once we couple that with the vertical dimension component, we'll be able to establish that vertical and maintain the mandibular denture in place by stabilizing the lower denture with the implants. This will then give our patient the functional esthetic and look she desires.
We're finally getting to the point of explaining where the vertical dimension is and how we find it. If we look at the two dentures in this case side by side, you can see there's about a 10 to 15 mm increase in our patient's final denture, versus the denture she came in with (Fig. 14). With the final denture, we have also included lifelike tissue modification. You can see the amount of soft and hard tissue being replaced with our denture acrylic to give us that increased vertical dimension (Fig. 15).
But how do you know where the vertical dimension is? Let's take a look at our starting point. In Figure 16, I measured the patient's vertical dimension with her existing dentures in place and, using a tongue depressor, made two marks on the depressor and some marks on her face. Then I measured her vertical dimension with the new denture in place. I have actually opened the vertical dimension a full centimeter (Fig. 17).
This is where we get into why Dr. Pound's article is so important. What I want to drive home is where that vertical dimension is and how we find it. What Dr. Pound considered to be a great starting point for vertical dimension was to use phonetics, or as in the title of his article, "Let 'S' Be Your Guide." Dr. Pound's article gives you the information you need to find the vertical component by using the sibilant sound or the "s" sound. When you say "s," a number of things happen. The lateral borders of your tongue will go up and touch the inner aspect of the pre-molars.
As the lateral borders of the tongue touch the inner aspect of the pre-molars, the tongue forms a groove. When the tongue forms a groove, air is expelled; that "s" sound goes over the maxillary central incisors and through the mandibular lower incisors. So with the sound "s," you're getting a lot of information.
The "s" sound will give you something called the "closest speaking space." The closest speaking space is where the mandibular plane and the maxillary plane are as close as they possibly can be to allow for your restoration, your full-mouth rehabilitation or your denture to function in the closest space that it can function within the patient's muscular realm. When the patient says "s," the mandibular teeth are approximately 1 mm from the maxillary posterior teeth. The sibilant sound, or the "s" sound, is your guide for vertical dimension.
With the sibilant sound, we discussed how the tongue braces against the pre-molars to say "s" — you can feel that. That "s" and the lateral border of the tongue will give you the patient's maxillary posterior tooth position by allowing it to fill out the buccal space. If the maxillary arch is too constricted, your patient may say "s" and come up with a "shushy" type sound. This also makes it very difficult for the patient to eat and chew.
So the "s" sound has to be a function of a vertical component — Dr. Pound's closest speaking space — and a horizontal component, allowing the tongue to fit into where the teeth should be. For a functional "s" sound, the maxillary anterior teeth and mandibular anterior teeth need to be positioned in approximately 1 mm vertical and 1 mm horizontal overjet, so that with the "s" sound the air is expelled over those teeth to give the patient a proper "s" sound.
If we look at the tongue depressor in Figure 18, we see about a complete centimeter. This brings us to the mystery of how I opened the patient up that much in the quick timeframe. I argue I didn't really open her up that much. To me, this patient was overclosed for too long, and by fabricating her new prosthesis utilizing "Let 'S' Be Your Guide," I really just restored her to her original position. So I really didn't open the vertical. I just found the proper position for her vertical dimension that was within the functional guidelines of her speech and desired esthetics.
Looking back at our patient's lateral view, we can see a loss of vertical dimension (Fig. 19). There are increased nasolabial folds and a long lower third. In Figure 20, with the vertical dimension opened up a full centimeter, look at what happens. She looks beautiful again. We have increased her middle third; we actually brought her middle third out to be almost parallel with her chin. We have rolled her lip out to give her an appearance of youthfulness. Her lower third has not really changed much; we've done all of the adjustments in the maxillary third. But with that increase of vertical dimension, notice her chin point. Something that comes up with increasing the patient's vertical dimension is, as you open it the mandible follows the arch of closure and swings posteriorly, bringing the chin back automatically. And that's what was created to give our patient a smile. If we look again at the red line on the facial in Figure 19, it completely demonstrates how she looked with her old dentures. Now if we draw the same line (Fig. 20), we have close to a vertical appearance, and it gives our patient the facial esthetics she desired.
But with all that said, there's a big negative here. With an increase in vertical dimension, one of the things that develops as the mandible swings downward is that the patient will gather an excessive amount of skin in the neck area. So once again, as you increase the vertical, the tissue underneath the patient's chin will begin to bunch up. Remember, our patient is very conscious of the way she looks.
She spoke to me about this and I told her there is nothing I can do about that; she needs to see her plastic surgeon.
So let's recap. The patient's existing denture — with an overclosed vertical, teeth set over the ridge — provided her with an older appearance, which she was not looking for when she had her dental implants placed. She thought implants would give her a more youthful appearance.
With the new denture, we were able to give our patient the tooth size and shape she wanted. We were able to bring the maxillary anterior teeth forward from the ridge approximately 13 mm, by the incisal papilla. We utilized Dr. Pound's "Let 'S' Be Your Guide" to develop and find where the vertical should be through her sibilant sounds, and that allowed us to develop the buccal corridor because our pre-molars were in the right position. So our sibilant sounds were fabricated through "Let 'S' Be Your Guide" — 1 mm vertical and 1 mm horizontal overjet of the maxillary and mandibular anterior teeth. This gave our patient the look she wanted.
If we take that tooth position and we look at where our patient wanted to be, using the cosmetic guidelines, and looking at her where her existing denture was (Fig. 21), and then the final with her lips together, you can see in Figure 22 there's a decrease in that nasolabial fold. She looks great, and now our patient is happy. We have met her expectations through the use of dental implants and have given her the superior smile she wanted and deserved (Fig. 23).
