CIKTRIC

RELATION
AND VERTICAL
DIMENSION
BY CEPHALOMETRIC
ROENTGENOGRAMS
JAMES

E.

PYOTT,

D.D.S.,

AND

AARON

Baltimore,

SCHAEFFER.

X.B.,

D.D.S., M.S.

Md.

HE PROSTHODONTIST
must establish the proper centric jaw relation
at the correct vertical dimension. This, of course, involves the determination
of the exact rest position. If this factor is not determined correctly in the beginning, the patient will suffer from too great a vertical dimension or overclosure.
that is, too little or too much free-way space. The symptoms are classic: irac-,
tured artificial teeth, midline fractures in the restorations, discomfort and poor
retention, loss of alveolar bone associated Lvith flabby- ridges, teml~oromnndihul;tr
ljain, sore ridges, and sore tongue.
\;lc have based the cephalometric technique on the work of t3roadbent.l and
the findings of Brodie and Thompson.~ These investigators have shown that the
position of the mandible remains in a constant relation to the skull during the life
(of an individual, and this position, the rest position, is determined by the muscles
which elevate and depress the lower jaw. This is: the position in which the mandible
is held most of the time when an individual
is not talking, swallowing, or
masticating.
The free-way- space varies in individuals, although it has been reported that
the average free-way space is 3 mm. From our experience, we have found that
most patients function well with that amount of free-way space between their artificial restorations.
(The patients exact free-way space can be determined 1,~.
making cephalometric roentgenograms of the jaws with natural teeth, prior to e:<.
traction. 1

CEPHALOMETRIC

TECHNIQCE

The cephalometer, used for determining vertical dimension and centric I+

lation, is shown in Figs. 1, 2, and 3. Six roentgenograms are made at the rest po;ition (Fig. 4). This is achieved by directing the patient into the rest position tq
having him swallow, by conversation to achieve relaxation, and by the repetition
of certain sounds such as m-m-c, or words such as Mississippi and Boston. Six
roentgenograms are made to pertnit comparison in order to insure accurac!; in
obtaining the recording of rest position.
Impressions, casts, and zinc oxide-eugenol
paste-lined occlusion rims
are made and Gothic arch tracers are used in the usual manner. To provide the
point which indicates centric relation at the proper vertical dimension, we depend
Read before the Academy
Rewired
for publication

of Denture
Prosthetics,
Aug. 19, 1953.
35

Los

Angeles,

Calif..

April

II,

19.53

PYOTT

AND

J. Pros. Den.
January, 1954

SCHAEFFER

Fig. l.-The
cephalometer.
A, The x-ray
unit is fixed so that its central
ray travels
through
the ear rods, and is located
at a distance
of five feet from the midsagittal
plane of the head.
B, The stabilizer
for the patients
head.
The head of the patient
is stabilized
by means
of
plastic rods placed in the patients
ears.

Fig.

2.

Fig. Z.-The
patient
in the cephalometer
ear rods in position.
The cassette
holding
Fig.

3 .-The

patient

in the cephalometer

Fig.
is in rest position,
the film is moved
is in rest

position.

without
as close
The

3.
dentures,
as possible
cassette

and with the

to the head.

is in position.

Volume 4
?;nmixr 1

CEPHALOMETRIC

upon a simple Gothic

occlusion rims are cut
ferred to an anatomic
to orient the maxillary

Fig.

4.-A

.1 ;

arch tracing unit (extraoral

or intraoral)
(Fig. 5 i . 11~~:
to an arbitrary vertical dimension, and the casts are transarticulator by means of a face-bow.
(The face-bow is used
cast on the articulator in the same relation to the contlvlar

roentgenogram
pogonion

Fig. S.-The

ROENTGENOGRASI

Gothic

of rest position.
The distance between
the nasion
(marked
A and R. respertively)
is 107L& mm.

arch

tracing

unit

with

the Gothic

arc%h tracing

and

inscribed

guidances as the maxilla has to the condyles.

It also gives the length of the
stroke from the condyles to the lower central incisors. ) -4 Gothic arch tracing unit,
is transferred
to the
set up at this arbitrary vertical dimension on the articdat~-Jr,
patients mouth to inscribe the typical tracing.
TVhen the centric point is located,
the point is fixed by cementing a piece of acrylic (with a hole punched into it)

38

PYOTT

AND

SCHAEFFER

J, lro~. Den.
January, 1954

directly over the centric point. The hole in the acrylic must be directly over the
exact centric point. Thus by having the patient close his mouth, the Gothic arch
unit pin falls into the hole in the acrylic, locking the patients jaws in centric POsition. At this time another cephalometric roentgenogram is made.

b.
a.
A hole is punched
in the tracing
at
Fig. 6.--a, Tracing
of the frOntOnaSd1
area.
A hole is punched
in the tracing
at pogonion,
b, Tracing
of the mandibular
area.
tracings
are superimposed
upon each roentgenogram
of the patient.
All six original
grams are punched
and should show a constant
distance
between
the points
A and
position.

nasion, A.
B. These
roentgenoI3 for rest

Fig. %.
Fig. 7.
The Hanau
articulator
is
Fig. 7.-Cephalometric
roentgenogram
of the patient
at rest.
superimposed
upon the film to show the distance
between
the condyle
and the mandibular
incisor
area.
Fig. 8.- Roentgenogram
of the patient
with the central
bearing
point and intraoral
tracing unit maintaining
the vertical
dimension
at centric
relation.
The distance
between
points
A and B is rO4jh mm.
The plaster
checkbite
is again inserted,
and the lower cast is remounted
at the correct
vertical
dimension
and centric
relation
on the articulator.

Tracings of the frontonasal

area and the mandibular area are made on
Trac-o-film paper from the roentgenograms
(Fig. 6). A hole is punched into the
nasal tracing by a pin point at nasion (the junction of the nasal and frontal
bones), and designated as point A. At pogonion (the most protrusive point on
the symphysis of the mandible) a hole is punched which is designated point B.
The tracing of the nasal area is superimposed upon each roentgenogram, and point

Fig.
checkbite.
imposed
relation.

B.
9.--A,
The Gothic
arch unit is in the mouth
in centric
position.
with
R, Roentgenogram
with the Gothic
arch unit in position
in the mouth,
upon it is the Hanau
articulator
adjusted
to the correct
vertical
dimension

the ylastel.
and superand cywtri,

The tracings are then superimposed

upon the roentgenograms
at centric
occlusion, and the holes A and B are punched at the nasion and pogonion.
These
are the roentgenograms
made with the tracer in centric position in the mot&
The distance between them in centric occlusion should he approximately
3 mm. lest
than at rest? or whatever amount of free-way space the operator desires to prrivide for the patient (Fig. 8).
If the desired free-way space does not exist, thr
Gothic arch unit pin must he adjusted up or clown so that the next cephalornetrir
roentgenogram
will show the desired free-way space. Of course, as the vertical
dimension is changed, a new Gothic arch tracing must 1~ inscribed, for with
changes in vertical dimension, the position of the Gothic arch tracing on the
tracing table changes.

B.

If a change of vertical
dimension
is necessary,
the change
F ig. 10.-A,
B, The vertical
dimension
ipers from the upper ridge to the lower ridge.
to allow 3 mm. free-way
space.
duced from rest position

F ig.
OCCIUE

three

ll.-Cephalometric
:ion.
The vertical
months.

roentgenogram
dimension
is 104%

showing
mm.
The

the finished
patient
has

is measured
with calin this case was : re-

replacements
in ten ttric
worn
the restorations
for

CEPHAI.OMETRIC

ROENTCENOGHh.llS

41

This procedure should be repeated tultil the desired free-way space has iwr
established, and then the lower cast is remounted at this corrected vertical dinwnsion by means of a plaster checkhite on the tracer (Fig. 9). \2heu changes iu thy:
vertical dimension are necessary, they can be matlv 1)~ measuring betwrcn tht
ridges of the mounted casts in the area of the central incisor5 with calipers ( Fig.
10). 110 not depend on measuring the change in the length of the incisal guide
pin, for this procedure does not reflect the amount oi opening or closing accura~cl ti
in the area between the ridges.
After the proper free-way space has been established, l.he teeth are set 111)an:l
tried in, a protrusive
checkbite is made, and the condylar guidances are SCI 01)
the articulator.
The restorations
are fabricated, ground in on the articulator and
finished. After the patient has worn the restorations
several weeks cephalomrtr~,r
roentgenograms
are made with the restorations
in position at centric occlul;ic:n
and at rest. The results should be consistant with the previous cephalomrtric,
readings used in making the restorations
(Fig. 11 I.

Cephalometric roentgenograms
have a place in making artificial restorations,
They are used for patients needing full restorations,
partial restorations,
ant\
when making the so-called bite raising appliances.
The object of this procedure is to present a scientific and esact method of &atermining rest and centric positions at the correct vertical dimension.
Using this method, the measurements at vertical dimension made in makinrr;
the restorations
may be checked and rechecked, before, during, and after the COJIpletion of the restorations so that the vertical dimension may be changed or veritivtl.
REFERENCES

1. Broadbent, B. H.: A New X-ray Technique and Its hpplication

to Orthodontia, Argle
Orthodontist 1:45, 1931.
2. Brodie A. G., and l?hompson, J. R.: Factors in the Position of the Mandible. J..4.D..\.
29:925, 1942.
3. Thompson! J. R.: The Rest Position of the Mandible and Its Significance to lkltal
Science, J.A.D.A. 33:3, 1946.
'206 MEDICAL
BALTIMORE

ARTS

1, MD.

BLDG.