Vertical control: A multifactorial

problem and its clinical implications

Meropi N. Spyropoulos, D.D.S., MS.,* and Monigeh Askarieh, D.D.S.,
MS.**
Ann Arbor, Mich., and Teheran, Zmn

T he concept of “vertical control” initially appeared in the orthodontic

literature about a decade ago. As aware orthodontists began to evaluate and re-
evaluate cases, the significance of this concept became one of the most important
concerns of current orthodontics.
What is meant by “vertical control”? Let us think about it first as dentists
and then as orthodontists. Control of vertical dimension in dentistry means as-
sessing, and or re-establishing, the individual’s proper vertical facial proportions
during operative or prosthetic procedures (for example, the tedious and meticu-
lous steps of bite registration during denture construction). In orthodontics, the
term refers to the orthodontist’s awareness of the possible changes in the vertical
facial dimensions of the growing orthodontic patient and the implications in the
control of these changes toward achieving the best possible end result.
The purpose of this article is to describe the changes that occur during ortho-
dontic treatment, to analyze the desirable and undesirable aspects of these
changes, and to survey the factors involved in their production and the clinical
implications of their control or lack of control.

Changes in the vertical fadcal dimensions

The changes that can be observed in the vertical dimension of a growing

orthodontic patient involve always the concept of relativity. To assess a change,
we have to compare two basic situations, values, or ratios. We should, therefore,
define in these terms what we are going to compare when we refer to changes and
focus our attention on the clinically significant ones.
If we compare the over-all vertical facial dimension on pretreatment and
posttreatment cephalometric tracings of an orthodontic patient by superimposi-

*Assistant Professor, Department of Orthodontics, School of Dentistry, University of

Michigan.
‘*Assistant Professor, Department of Orthodontics, National School of Iran.

70
 Vertical conlrol 71

tion on SN and registration at S (or on DeCoster’s line), we may observe one o1

the following :
A. A harmonious increase in the anterior as well as the posterior facial
heights, with the palatal, occlusal, and mandibular planes changing
in a parallel direction. This would give constancy in the pretreatment,
and posttreatment ratio of the upper (N-ANS) to the lower (ANS-31)
anterior facial height; also, in the ratio between the posterior facial
height (Ar to mandibular plane tangent to the posterior border of the
ramusls) and the lower anterior facial height. This type of change: will
be referred to as change type A.
B. An increase in the anterior facial height without a proportional in-
crease in the posterior facial height. An accompanying feature is a
backward movement of the chin, expressing a downward and backward
rotation of the mandible (clockwise). This lack of proportionality of
anterior facial height increase as related to the posterior facial height
increase may be due to (1) an increase in the X-ANS distance, (2) an
increase in the ANS occlusal plane distance, (3) an increase in the oc-
clusal plane-mandibular plane distance, and (4) a combination of all
or some of the above. Consequently, there may be a change in the ratio
between the upper and lower anterior facial heights as well as in the
ratio between the posterior and anterior lower facial heights. This type
of change will be referred to as cha.nge type B.
C. An increase in the posterior facial height without a proportional in-
crease in the anterior facial height which might have increased to a
lesser degree or not at all. An accompanying feature is a forward and
upward rotation of the mandible (counterclockwise). In this case, there
will also be a change in the ratio between the posterior and lower an-
terior facial heights. This type of change will be referred to as change
type C.
D. The fourth possibility that exists is rather rare; it is the possibility of
no relative or absolute change whatsoever. This is most likely to occur
in nongrowing (adult) patients and will be referred to as chrrngr: type
D.

Andysis of the changes mentioned

Desirable and undesirable chatages. Usually in patients with Class I maloc-

clusions with a lmlanced skeletal pattern with satisfactory anteroposterior jaw
relationship and no facial hyperdivergence,lF type A change is most likely to be
seen, with the chin moving in a downward and forward direction. This type of
change is also the most desirable since the facial balance remains undisturbed.
In patients with hyperdivergent facial skeleton and a steep mandibular
plane, there are two subcategories :
1. Those with a convex profile, an increased ANB angle, and a Class II,
Division 1 malocclusion accompanied by an open-bite tendency. In
these patients, the most probable changes are those of type B, which arc
72 Xpyropoulos and Askarieh Am. J. Orthod.
July 1976

also very undesirable because they (1) result in an increase of facial

hyperdivergence, (2) accentuate the chin recession and the facial con-
vexity, (3) accentuate the anteroposterior jaw discrepancy (B point
moves downward and backward), (4) accentuate the lower anterior
facial height which is usually long already, and (5) increase the open-
bite tendency.
The clinical problems related to these changes are: difficulty in re-
ducing the ANB angle, difficulty in correcting molar relationship, and
extrusion of upper incisors to overcome the open-bite tendency. The
extrusion of the upper incisors makes torque control a problem and
causes display of upper gingival tissue on smiling. On the other hand,
for this type of patient, change type C is very desirable as it will affect
favorably both the profile and the correction of the malocclusion.
2. Those with a concave profile, a negative ANB angle, and a Class III
malocclusion described by Tweedz3 as Class III, Category B malocclu-
sion.
In these patients, the change type B, by moving B point posteriorly,
tends to reduce the anteroposterior jaw discrepancy and to decrease
the chin protrusion. Yet, this type of change has the following undesira-
able aspects: (1) it increases the facial hyperdivergence, (2) it in-
creases the open-bite tendency, and (3) it accentuates the length of the
already long face.
We cannot, however, claim that change type C would be desirable
either. Depending, therefore, on the severity of the case, surgical ortho-
dontics sometimes provides the solution of choice.
In patients with hypodivergent facial skeleton with a very flat mandibular
plane, decreased anterior lower facial height, and deep-bite tendency, there are
also two subcategories :
1. Patients with an anteroposterior jaw discrepancy expressed by an in-
creased ANB angle and a Class II, Division 2 malocclusion. In these
cases, the most desirable change is type B because it would (1) increase
the lower anterior facial height and thus improve the facial profile, (2)
help in the correction of the deep-bite, and (3) correct the hypodiver-
gency of the face. However, this type of change would also accentuate
anteroposterior jaw discrepancy (through the downward and posterior
movement of B point) and increase the ANB angle. In order to assess
correctly the clinical significance as well as the desirability of type B
change, we should, however, take into consideration the fact that, in
many of these cases, the large ANB value is due to a posteriorly locked
mandible and a very upright position of the upper incisors, causing
the A point to come forward.
2. Patients with a concave profile, a negative ANB angle and a Class III,
Category A malocclusion. 23 In these cases, type B change is desirable
as it will have a beneficial effect on both the profile and the correction
of the malocclusion.
Type C change is undesirable as it will (1) accentuate the concavity
 of the face by bringing the chin forward, (2) increase the tendency for
deep-bite, (3) accentuate the hypodivergency of the face, and (4) de-
crease the already reduced anterior facial height.

Factors involved in changing the vertical facial dimension

&o&h. Ever since the publication of SchudyW article on the effect of

vertical versus anteroposterior growth upon facial type, a new aspeat in tlls
evaluation of orthodontic cases came into focus; this aspect is oriented toward
the factors causing downward and/or forward movement of the chin during
growth. Some years earlier, Scott 22 had observed that ‘icertain types of faCeS are
associated with a tendency toward certain kinds of malocclusion.” Through the
study of “the facial frame,” the “pogonion formula,” and the “clockwise” and
L’anti~lo~kwise” rotation of the mandible, 18,10 the mechanism of growth in hyger-
and hypodivergent faces was documented. It is well understood today that the
differential growth at the condyles and at the molar alveolar bone is responsible
for the rotation of the mandible and hence the position of the chin.
If the total vertical growth of the face (that is, the growth between the
cranial base, the palate, the occlusal plane, and the lower border of the mandible)
equals the total increase in length of the mandible through condylar growth,
then the chin grows downward and forward in a uniform pattern; if we super-
impose progress head film tracings on the Ala-nasion plane registered on R, WC
observe that the mandibular plane remains parallel to t,he original.‘”
More vertical growth at the molar area than at the mandibular condyles re-
sults in a clockwise rotation of the mandible (type B change). On the other
hand, counterclockwise rotation of the mandible (type C change) is a result of
more condylar growth as compared to vertical growth at the molars. In other
words, an increase in the vertical growth at the molar area has the same effect on
the direction of the chin as a decrease in the condylar growth and vice versa,2o
Clinical observations and studies of cephalometric films of both orthodontic-
ally treated and untreated patient+ 3, l3~16 provided us with some indications of
the probable growth potential of the various skeletal patt,erns. These indications
can be summarized as follows:
1. The degree of facial divergence has an effect upon the degree of rota-
tion of the mandible; that is, the more divergent a face, the greater the
tendency toward vertical growth.
2. The size of the gonial angle affects the amount of rotation of the man-
dible; that is, the more obtuse the angle, the greater the tendency
toward vertical growth.
3. The greater the antegonial notch, the greater the tendency toward ver-
tical growth.
Treatment. Several studies on orthodontically treated patients as well as on
untreated persons have documented the fact that forces applied to the teeth
through orthodontic appliances have a substantial influence on the vertical facial
dimension. This influence is as follows :
1. Extraoral forces. One of the most extensively studied forces used during
orthodontic treatment is the one applied through extraoral anchorage.
74 ~p~rOpOul0s ad flskarieh Am. J. Orthod.
July1976

The first appliance used in this respect was Kloehn’s cervical face-bow.
Ever since, many modifications of the original pattern have been made,
with the hook-on headgear type extensively used. Klein6 was one of the
first investigators to report a retardation in forward movement of
point A and a downward tipping of the anterior aspect of the palatal
plane in patients undergoing treatment with extraoral force. Schudy17
documented these findings, and since then a number of authors have
studied the influence of the direction of pull of the extraoral forces on
the teeth and the palatal and occlusal planes.1s 3t s-11>24 The conclusions
from these studies seem to coincide in that the direction of pull of the
extraoral forces can influence the direction of mandibular rotation. If
the direction of the extraoral force is :
A. Downward and backward, that is, cervical pull, there may be ex-
trusion of teeth, resulting in a potential clockwise rotation of the
mandible, causing the chin to move downward and backward. There
may also be a potential for temporomandibular joint disturbances as
the teeth move into the freeway space and the condyles are guided
into new positions so that the teeth occ1ude.14
B. Backward in a straight direction, that is, straight pull, there will be
no extrusion of teeth and hence no influence on the movement of
the chin.
C. Obliquely backward and upward, that is, high pull, there will be
control or even suppression of the eruption of teeth which will mini-
mize the clockwise rotation of the mandible or even enhance an anti-
clockwise rotation ; this happens by allowing the growth of the con-
dyles to be expressed in a forward direction since the growth at the
molars is minimized or eliminated.
The orthodontist’s decision as to what kind of pull should be used
in each case should be based on the results that he wishes to obtain on
the facial esthetics.
2. Internzaxillary elastics. Intermaxillary elastics may cause extrusion of
teeth and changes in the facial vertical dimension. RickettPv I3 re-
ported a 2.5 to 3.3 mm. elevation of the lower first molar after use of
Class II elastics. It is worth while mentioning how well aware Tweed
was of this fact. Even though it has never been precisely mentioned by
him, the whole concept of anchorage preparation in the lower arch as a
prerequisite for the use of Class II elastics is an answer to the side ef-
fects of their use.
The most common types of intermaxillary elastics used in orthodon-
tic treatment are:
A. Class ZI elastics. If used with care on a prepared and stabilized
lower arch, the amount of tooth extrusion can be minimal.
B. Class III elastics. If used in conjunction with the appropriate direc-
tional extraoral force, tooth extrusion can be very well controlled.
C. Vertical elastics. Used usually when extrusion of teeth is indicated
or to counteract intrusive forces applied through other procedures.
 D. Cross-bite elastics. They may cause a certain amount of tooth ex-
trusion.
3. Arch wires. Any arch wire can cause extrusion of teeth, depending on
the irregularity of the teeth, the severity of the curve of Spee, the
shape of the arch wire, etc. A reverse curve of Spee in a mandibular
arch wire applied on an already leveled dental arch is said to cause ex-
trusion of the premolarsi which, in turn, will influence the rotation of
the mandible in a clockwise manner.
4. Bite planes. Bite planes may cause an intrusion of the lower incisor
teeth and/or eruption of the upper and lower posterior teeth. They,
therefore, may influence the rotation of the mandible.
5. Actiuutor. It is reported in the literature that the use of an activator
can influence the vertical facial dimension in growing persons; this
depends on which teeth are stopped by the plate occlusally and which
are left free to erupt.4 Clinical experience, however, supports the view
that the use of an activator is contraindicated in cases with a very
steep mandibular plane and increased lower anterior facial height.
6. Orthopedic forces.
A. Palntal expnGo?l. The effect of palatal expansion on the facial ver-
tical dimension is very well summarized in the following: “The
change in maxillary posture (forward and downward movement
of point A), invariably causes a downward and backward rotation
of the mandible which dec.reases the effective length of the mandible
and increases the vertical dimension of the lower face.“”
B. Chin cop. The use of a chin cap may influence t,he vertical dimension
of the lower face by holding or pulling the chin upward. It is in-
dicated, therefore, in combination with the palatal expansion procc-
dure when clockwise rotation of the mandible is undesirable or in
cases with increased lower facial height and a tendency toward man-
dibular prognathism as, for example, in early treatment of skeletal
Class III cases.
Combimtio?L of the above nzention.ed factors. One of the current concepts of
orthodontic diagnosis and treatment is that “terminal growth and differential
anchorage are relied upon for the final harmony of the masticatory apparat,us.‘“’
It is, therefore, obvious and of the utmost clinical significance that the ortho-
dontist should be well aware of the effects that any of the possible combinations of
the above factors may have on any specific case. IIis efforts and success in control-
ling them are the essence of vertical control.
Unfortunately, Creekmore” says, “the high angle faces tend to become even
higher, whereas the low angle faces tend to get lower.” However, “the control
of posterior tooth eruption is the most manageable factor available to t,he ortho-
dontist in the overall control of anterior vertical dimension of the lower facc.“8
In patients with steep mandibular planes and unfavorable growth patterns,
it seems that the musculature (force and direction of muscle pull) is also nn-
favorable; molars will extrude readily in response to even the lightest forces and
will seldom reintrude after the end of treatment. On t,he contrary, in patients
76 8pyropoulos and Askarieh Am. J. Orthod.
July1976

Fig. 1. A case illustrating the effect of good treatment on the “vertical control.” In this
case, growth did-not help in any respect and the very satisfactory end result was achieved
by treatment procedures alone.

with flat mandibular planes, it is usually very difficult to cause extrusion of the
molars and hence clockwise rotation of the mandible ; furthermore, if this ever
happens during treatment, there is a strong tendency toward reintrusion and re-
establishment of the flatness of the mandibular plane through the influence of
the musculature.
The main conclusions as regards the effect of the combinations of growth
and treatment procedures on the vertical facial dimension can be summarized
as follows :
A combination of proper treatment procedures with a poor skeletal and
muscular pattern and growth or a combination of poor treatment planning with
a favorable skeletal and muscular pattern and growth can create tolerable results.
On the other hand, a combination of improper treatment with a poor skeletal
and muscular pattern and growth can turn out to be literally disastrous.
Case reports
The cases selected for discussion in this article were treated in the Depart-
ment of Orthodontics of the University of Michigan by graduate students.
Core 1
M.S., a 14year-old, girl, had a Class II, Division 1 malocclusion, a high mandibular plane
?ngle, and an open-bite. The case was complicated by an excessive amount of crowding in
both the mad& and mandibular arches and an overjet of 8 mm. Taking into consideration
 Vertical control, 77

Fig. 2. A case illustrating the undesirable effects of “clockwise” mandibular rotation.

This occurred because growth at the condyle did not compensate for the extrusion of the
molars. The forces used during treatment were not the proper directional forces.

the age and sex of the patient as well as her skeletal pattern, one can realize the problems in-
volved in the treatment of this case.
The patient was treated for 2 years with a full-banded edgewise Tweed technique, and
treatment involved the removal of all first premolars. Throughout the whole treatment period,
anchorage and vertical control were taken care of with directional extraoral forces, namely,
high-pull face-bow, straight-pull headgear, and high-pull headgear. Toward the end of treat-
ment, vertical elastics were used in conjunction with the high-pull headgear to establish proper
vertical relationship of the anterior teeth.
When superimposing the tracings of the pretreatment and posttreatment cephalometric
x-ray films on SN registered on S (Fig. l), we can observe the following:
Growth did not help whatsoever in the treatment of t.his case and the corrections achiev-i4
were the results of accurate and proper treatment procedures.
As regards vertical control in this ease, we can characterize it as very satisfactory. None
of the undesirable changes (type B) took place, since there was no increase in the mandibular
plane angle, the ANB angle, or the lower anterior facial height.
When we superimpose the before- and after-treatment, tracings of the upper and loner
jaws separately, it becomes obvious that no extrusion of the molars took place, which is to
the credit of the treatment procedures used.

Care 2
LX., a 12-year-old girl had a Class II, Division 1 malocclusion, a convex profile, and a
deficient mandible; there was a high mandibular plane angle, an excessive maxillary and
moderate mandibular crowding, an excessive overjet, and a minimal overbite.
The period of active treatment, which involved the extraction of all four first premolar’s
was 2 years with a full-banded edgewise technique; the patient was very cooperative. Yet,
78 Spyropoulos md Askarieh Am. J. Orthod.
Jztlf/ 1976

Fig. 3. The favorable growth that occurred in this case made possible the completion of
treatment just with the use of the activator.

when we superimposed the tracings of the pre- and posttreatment cephalometric x-ray films on
SN, registered on 5, we have to admit that this case lacked vertical control (Fig. 2). The
negative factors involved in this case can be summarized as follows:
Unfavorable growth. The tendency for vertical growth which this case exhibited
before treatment was expressed in its maximum during the treatment time.
Improper treatment procedzcres. The forces applied during treatment were not the
appropriate ones to minimize the expression of the mandibular growth in a vertical
direction ; on the contrary, by their use, both the upper and lower molars were ex-
truded (Fig. 2). As a consequence, type B change occurred; that is; the lower anterior
facial height increased, the whole lower face dropped backward and downward, the
soft tissues appeared strained, the convexity of the face increased, the nose became
more prominent in the convex profile, the upper incisors extruded, and a substantial
amount of gingiva was displayed upon smiling. Going through the record of this pa-
tient, we can pinpoint the causal forces during the various stages of treatment:
straight-pull extraoral forces, Class III elastics, and excessive reverse curve of Spee in
the lower leveling arches.
This case illustrates very clearly the detrimental effects that a combination of improper
treatment procedures and unfavorable growth may have on orthodontic objectives.

Case 3 (Appliance used: AcfivaWr)

When the activator is used in the Orthodontic Department of the University

of Michigan, it is generally as a precomprehensive orthodontic appliance ; the
cases treated initially with the activator usually undergo a later second stage
 Vertical codrol 79

of full-l)an&d comprehensive treatment. The ease 1)resented here was an c~ccl)-

tion to tlic rule and was selected because trcatmcnt was completed with the activa-
tar alone as the growth was estremcly favorable.
A 12-year-old boy, P.C., with a Class II, Division 1 malocclusion, an excessive overjet, and
a deep overbite was subjected to activator treatment. He was a very cooprratiw patient, :~ni
his active treatment was completed in 16 months without any need for further treatment, 1”‘”
cedures.
The superimposition of the tracings of his pretreatment and posttreatment cephalometri(,
films on SN, registered on S, shows some very satisfactory changes (Fig. 3 ). The palatal, o(’
clusal, and mandibular planes remained parallel. The overjrt as well as the owrbitc KCW ~c’r!
much reduced, and the lower face as a whole came forward and dowwnrtl.
In this case, growth was the unique factor for the correction of the malocclusion; tlrl$
treatment procedures did not extrude the molars and, therefore, did not interfere \vith It e
maximal expression of the favorahle growth potential.

Summary

In this article we have tried to analyze the importance of vertical control in

orthodontic cases, as well as the factors affecting it. From the cases presentett,
it can be assumed that :
1. In vertically growing or nongrowing persons (high-angle cases), thelap-
plication of proper directional forces becomes cstremely critical because a cloclr-
wise rotation of the mandible can occur very promptly and is very undesirable.
2. In cases with favorable growth potential, the results may be acceptable, even
if the forces applied during t,reatment arc not absolutely controlled; in other
words, Mother Xature may often compensate for inappropriate or miscalculated
treatment procedures.

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Angle Orthod. 37: 285, 1967.
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5. Haas, A. J. : Palatal expansion: Just the beginning of dentofacial orthopedics, Ant. .I.
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chorage, Angle Ort.hod. 38: 341, 1968.
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80 Spyropoulos and Askarieh Am. J. Orthod.
July 1976

14. Roth, R. D.: Temporomandibular pain dysfunction and occlusal relationships, Angle
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THE JOURNAL 60 YEARS AGO

July, 1916

The question of postgraduate instruction in the dental profession is at the present time
somewhat of a problem, and courses are only in a developmental state. Among the first
endeavors which we noticed of a post-graduate nature were the study clubs, which it
is our impression were organized first in Iowa by men who took up certain lines of work
under the tutelage of prominent men in the profession. The activities of these study clubs
in Iowa had a very marked effect, for it seems that the dental profession in Iowa dis-
played greater interest in this subject than is manifested anywhere else by dentists in the
United States. The plan adopted by these clubs could be followed advantageously by
dentists in other parts of the country. (Martin Dewey: Editorial. Orthodontia and Post-
graduate Instruction, International Journal of Orthodontia, predecessor of the American
Journal of Orthodontics, 2:328, 1916.)