.

4 CEFHALOMETRIC

STUDY OF THE CLIXICAI,

THE MASDIHLE

REST POSITION

HEN fil;qX ATTEMPTS

OF

TO measure a phydogic process, he usually is

frm one human being to another, and by variability in the samehuman being from one examination to another. Each physiologic
process has a range of varialdity which is compatible with health. If this range
is excectled, the individual l~econw sick. and the physiologic state I~econws a
pathologic state.
Moreover, each physiologic proccs~ has ;I range of variability which is charartenstic for that proms. For cxui~pl~, the range of variation of blood pfl is very
small. whereas the range of variation ior hotly weight is greater.
,1lans ability tcl detect this wri;ll)ility depends on : (1 I the accuracy and
validity of his measurcnients, (2) tlw number and timing of his measurements,
and i.7 ) the degree of variability oi the phvsiologic process.
The so-called rest position of the n~andihle is generally considered a physiologic
state established hy the Idance of antagonistic muscle forces. Our ability to detect
a variability oi the rest position clclxnds on : ( 1I the accuracy and validity of our
nieasuremcnts of the rest Imsition, (2 I the niunbcr and timing of our nieasurcmnts, and (3 1 the variahilitv of the rest position.
711~~lrcrwac~ (711d Jalidity (J,( .llra.urmnrnts
of thr K~.rt Posilim---The ohWining of accurate measurements of the resting vertical diiiiension by the usual
clinical nxms is hampered 1)~the following disadvantages: ( 11The nleasurernents
are Illa&
011 Wft tisSw% (2 I Manip~~lation about the face is necessary at the
mnnicnt of nieasurmimt with measuring devices. (3i The concentration is on
the mawring device instead of on the patient. (-I\ The lack of permanent record
and of permanent reference points to return to at suhscquent esaniinatinns.
The advantage5 (I[ the cephalornetric method arc : (I i Measurements are
ma& nn hony points. (21 No mar~ilmlation ahout the face is required mm the
patient is seated coniirmnl~ly. 13 1 Couccntraticrn is p!aced o11 the patient and
his state of rest rather than 1111
the measuring device. The patient is less jawconscious. (-I 1 .-\ perument record ant1 l~ertnanent reference points are avail;Il)le tcr return to months or years later.
The disa(lvantagcs of ihe ceyhalometric mthnd arc : il I The measurements
are made in strangScsurrounditl,qs for the patient. including ear-posts. (2) The
measurenwnts are ma&~ of shadow 1)icturcs. (31 Sped quilmcnt is required. (-Vi The use d s-ra\s is newwar\-.

W confronted 1)~ variability

Read heforc bhe Arademv of Denture Prosthrtivs.

Received for publication. SOY. IO. 195,.
.-IO4

Sew York.

S. Y.. May 6. 19.X

Volume 6
Number 4

CEPHALOMETRIC

STUDY

OF

REST

POSITION

OF

MANDIBLE.

505

If the equipment can be obtained, the other disadvantages can be overcome with
the exercise of due care. The measurement of the rest position by any means is
a clinical procedure and must be done by a clinician and not by a technician, for
every time the operator pushes the x-ray button or uses the bite-gauge, he must
make a complex clinical evaluation of the patient, deciding that the patient is truly
at rest. Therefore, the validity of the measurements depends on the clinical
understanding of the operator and on that intangible doctor-patient
relationship
To emphasize this important human
which is conducive to patient relaxation.
factor, I refer to the clinical rest position rather than the physiologic
rest
position.
The Number and Tinzing of the Measurements.-In
order to prove that the
rest position is constant from birth to death, one would like to make measurements
in the same individuals throughout their lives. Obviously, this is impractical.
However, we may get some clues by making several observations in one examination (or sitting) and then by making several similar examinations weeks or months
later.
Another approach is to look for pathologic situations, for if there is no measurable change during pathologic situations, there probably will be none during
physiologic situations. The most common major sudden pathologic event which
might affect the rest position is the extraction of the remaining occluding teeth.
I shall refer to this as the removal of occlusal contacts. Clinical experience suggests that changes often do occur at this time, but because of the problems of
measurement discussed above, good concrete data is very meager.
The Variability of the Rest Position.-On
purely theoretical grounds, there
may well be variability of the rest position, because the rest position is actually
a postural position, and should be subject to the same physiologic and pathologic
factors as is posture anywhere else in the body. Some of these factors are listed
in Table I.
TABLE

PARTIAL

LIST

OF FACTORS

I. Physiologic
A.
B.
C.
D.
E.
F.
II.

Voluntary control
Postural reflexes
Fatigue and sleep
Psychic factors
Heat, cold, or pain
Function

Pathologic
A. Diseases of muscles
B. Diseases of nerve
C. Diseases of bone
D. Diseases of joints
E. Any disease causing fatigability
F. Anesthesia and sedation
G. Mental diseases
H. External factors (e.g., prosthesis)
I. Malfunction

I
WHICH

INFLUENCE

POSTURE

J. Iros.
July.

SO6

Den.
1YS6

IJcspitc the ntttncrws factors \vliich ina~. i~~lluc~icc posture, and similarly
jaw pos:turc, it ntay be that becausc~(Ii the sntall size d the structures involved,
lhc possiLlc changes tit;iy Ix tw stitall tu ttic:i5111c,cspccially bvhrti crtttlc meas\ixds.
tli(:
INlgc!
Ui \.~lri~i~~Oll
lll~l\
!X
hJt1
Sliia!!
uring tlcvices are ii~c(l. 111 Other
to
nieasurc. Ii such i> the: c:LJ~,tllca r(d 1xbitiott \vill :i!qwar cotistattt iii htll
physiologic and 1~athologic situations.

Pll~ib i5 ;t rqm-t c.bi;i c~1~lial~~tttctric ~trt~l> ;~t tlic I I:tr\md School of I)eiital
.\ledicitic :ttitt at tlic \(4cratts X(lttiitti~trati~~ti I Io>l)it;i! itt I!u.itoti. \vitli ,\largolis
lar:~llel
Cq.11;110stats (,csccpt c.zl.c~ 1.3) alit! mlitiar~~ (t(~1ttal s-r;ix Itidtitiw
studies \\we conductc~t ;tt tlte two ittstittttiutls lo xv1 ;t \vit!cr \m?et!. ui l~hy~iologic
and l~;~t!iologic situaticul... lhc ittaiti r~.cltiirc~nit~ttt it lr tltc scltctioti (Ii a patient wxs
did

there

be

SOiiic:

ddiiih!

lxx!~tS~i!

cmhch

\v!k!i

\v?t-e

42 patients had to saLi)- this rcclttircttt~iit antI to lmwnt

:l

!)USy

C!illka!

X!lCd~l!(.

~cr!l;l!).i

icJrt~ttl~lli~!)~,

t!li:,

kls

ivory toud
L4ttu.l~~
tti tlie ~~ttit~lrcc~35~>t I: .L lllli\ IrYitjesnminatiotts were tii;~(!t. \\hmc~\u fv:~,~il~tv;ic~w(tiiig

tCJ

!JC

rctitUve(!

!<ac!i

the

himself at a titiic to lit into

!1CCll
;i clitiical stu(lj., ttot att
Ol- :I !IO5!)ih!.

(~c!)!l:l!~Jlll~trk

to ;I gcttmil plait. L-s:ually,

t\fXJ
Or t!lrW
li!ilh
\vcrC
t~lkell
\vit!l
the
!Xlhmt
clt
rest.
lhc \wtical tlitnension
\V;IS nwasuret! 011tlic. lilttls irottt tta~i011
to h~~tt;~t!iioti arid :t\.cmgd
ior ewh bitting.
As a clicck agaittd I~ussitJc mws iti tti;igttilicatic~ti tlticr to rtt:tll)~itionittg of the
patient, the constant c!ist;riicc irottt n:t~icm to ti;lsat q)ittc \V;LZtit~~;t5ttre~!1bt1eactt
li!tii, ant! this almost invariably 1m)vul to IJV wttst:ttit for cwlt lmtielit cm the films,
iticlic:itittg :t very higIl xcttracv 0i ttie:btirulicvt ant! I);ttir.ttt l~o~itiottittg. cacti though
ttte study included apIm~xitit;it~~!~ 300 -,clj:itxt cs bittitigs owr ;t four-our period.
Llic general l)l:itt \v;is to iotlou~ d&I!!- 111~.rcstitig vc.rtic:tl tlinicttsion before
a1td aitrr the rettimx! (Ii the rctttnittiti~ 0c~I11~:ttccmtxts.
S1m4ically, the proplms ittdicatet!
wtlttrc was as ic,!lubb : Iatiettts \\~Iios(~di;igttcAr; :m! trwtiiiuit
the rctitova! of rctit;iitiitig CKX~IUSillcolit:ict5 11(*t-c r~iuxd
to tltc investigator for
furt1tc.r \vorkup prior to tlw cstractirlti of ttw twtlt.
111~ittvcstigator chatted
anii;t!)!v with the patimt. too!; ;t tiie~li~~~l antI (!utt:tl liiitcq. oti ;i 1qxtretl fornt,
ant!, in ttiost instances. took color l)hotc-qr:~l)!ts r)i ttic. tmiiaining teeth and of the
facial lmfilc.
13~ the lititr tlic in\-estigxtor \~x.. txtt!~- to m~kc the tmelinc cephalometric esaniinatioti, tlw patiettt uxs it] III~C~ c;w*; clttitv relascd ant1 cooperative.
In fact! most patieltts mljrtstct! clttitc rcxlit!~ to ~IIC cc1)halostat, taking it as a matter
of course as just uiie time diagnostic lmduw.
Ii for atty reason, at the time
0i this baseline tn~asttretnctit, lltc patictttl \v:ts tlctwwct too apprehensive
or unable
to adjtist to the cephalostnt. he \v;is not ittclutl~d itt the study. Every effort was
made to prcvcnt thr Imticnt irottt Iwclmiitig j;i\~-con.iciOus or rest position
conscious. The ccph;i!ottietric csatttitt:itiun~ \\w-t~ csI)lnined to the patient onI>
itt broac-!tcrtiis of helping in thca later cottstructiott of the clcntttrcs, as, in fact, thev
usuatl~~did.
50 effort wns riiatlt~ tu conditicm the !mticiit tltrough exercises or pretiiedicntiott. Froni
the vcrv Ix~gitttiing, iv(- II:IVC*\\.:ttltct! 1t~ y~ut!!. the effect of specific
ljttt \YV ictt that we tnust first establish
remedial cscrciscs (or conditioiting!,
sonic sort of a haselinc from which \vv cou1~! tttwsitrc Ihe effrctiveness of the
rmecliat therapy.

Volume 6
Number 4

CEPHALOMETRIC
PRESENTATION
DATA

STUDY
OF

OF

REST

NEW

DATA

PRESENTED

BY

POSITION
AND
OTHER

OF

MANDIBLE.

COMPARISON

507

WITH

WORKERS

When one deals with 42 human beings, averages, mean deviations, and even
standard deviations mean very little to that individual who stands at one extreme
or another. All data is presented in the appendix for later analysis, but, despite
the inherent dangers in so doing, let us examine some examples and some averages.
Analysis of the data shows that the rest position may vary within a single
sitting between consecutive films, if the patient is allowed to talk and to return to rest.
This varies from one patient to another, some varying only slightly (Nos. 13, 32,
59, 60, etc.) with others varying quite considerably (Nos. 88, 96, 104, etc.) and
with others falling in between.
Likewise, the rest position may vary between different sittings, either a slight
amount (Nos. 32, 59, 65, etc.) or a substantial amount (Nos. 78, 88, 96, etc.) with
many graduations in between.
Analysis of the data presented by Coulombe and by Thompson and Brodie
The data from all three
and Thompson* reveals remarkably similar findings.
studies has been analyzed in the same manner and is summarized in Table II.
The above observations were in relation to the patients only after the occlusal
contacts had been removed. If one compares the pre-extraction rest position with
the post-extraction rest position, one finds even greater variations, which again
vary from one patient to another. Of the 42 patients studied in this manner, 11
patients showed an increase in resting vertical dimension, 9 showed a fluctuation
about their individual baseline measurements, and 22 showed a decrease. Table
II shows a summary of the individual variations in terms of both average findings
and maximum changes. Careful analysis of Thompsons five patients shows remarkably similar trends.
In most of the patients, observations were also made after dentures were constructed. It is interesting to note that the resting vertical dimension was often
different depending on whether the dentures were in or out of the mouth. In some
cases, the removal of the dentures was associated with a decrease in resting vertical
dimension, while in others there was an increase and in others, little or no change.
For example, in No. 13, there was little or no difference, whereas in No. 56, there
was an average decrease of 2.5 mm., and in No. 75 an average increase of 2.2 mm.,
even though all three showed an adequate free-way space with the dentures in
place.
CLINICAL

INTERPRETATION

OF THE

DATA

(SEE

APPENDIX)

The removal of occlusal contacts is a major, sudden, pathologic insult to the

entire stomatognathic system. Not only are mechanical factors upset, allowing
a range of motion (overclosure) which would otherwise be impossible, but also
biologic processes are disturbed when the proprioceptive nerve endings in the
periodontal membrane are destroyed. The edentulous state in the adult is a
pathologic state. The data presented suggest that, like other measurements of
physiologic processes, measurement of the resting vertical dimension in the edentulous patient shows a range of variation which varies from one patient to another
and in the same patient from one time to another.

- .-

.--_.-

-...

-:

5-

Volume 6
Number 4

CEPHALOMETRIC

STUDY

OF

REST

POSITION

OF

MANDIBLE.

509

Because of the variability and complexity of human beings, it seems imperative to emphasize that no attempt should be made to translate any of this data into
any magic numbers or rules which wotlld then be applied to all patients. This
type of oversimplification
often breeds confusion, as in the case of the free-way
space. It may be true that the interocclusal gap is very often 2 to 3 mm., but by
no means is this invariable.
To observe variability is one thing; to explain it, another. Why did some
patients vary more than others ? Why did the resting vertical dimension increase
following the removal of occlusal contacts in some patients, while decreasing in
others? The problem is much too complex to make a simple categorical reply. In
order to try to unravel some of the important threads, the 42 patients in this study
were analyzed in regard to many factors which will be discussed in Part III in
this article.
The fact that there was an average closure following the removal of occlusal
contacts in 22 out of 42 patients of 3 mm. does not answer the question as to
whether we can safely restore this lost vertical dimension with dentures. This
important clinical question will be taken up in Part II.
SUMMARY

1. For each physiologic process, there is both a physiologic and a pathologic

range of variability.
2. Mans ability to detect this variability depends on: the accuracy and
validity of his measurements, the number and timing of his measurements, and
the variability of the physiologic process.
3. The variability of the resting vertical dimension was studied clinically in
42 patients. By timing the cephalometric measurements before and after a major
pathologic event-the
removal of occlusal contacts-variability
should appear, if
it does occur and if it is measurable.
4. Variability was measurable and of clinical significance in edentulous patients
between different readings within a single sitting, between average readings of
different sittings, and between readings with and without dentures. Even greater
variations existed between pre- and post-extraction readings.
In each regard,
variability was different for different patients and for the same patient at different
times.
5. Of the 42 patients, 11 showed an increase in resting vertical dimension
following the removal of occlusal contacts, 9 fluctuated about their individual baselines, and 22 showed a decrease.
6. The fact of closure in 22 out of 42 patients does not answer the question
of safe restoration of lost vertical dimension with dentures. This question will be
discussed further in Part II.
REFERENCES

1. Coulombe, T. A. R.: A Serial Cephalometric Study of the Rest Position of the Mandible
on Edentulous Individuals, J. Canad. D. A. 20536-543, 1954.
2. Thompson. J. R.. and Brodie, A. G.: Factors in the Position of the Mandible, J.A.D.A.
29:925-941, 1942.
3. Thompson. J. R.: The Rest Position of the Mandible and Its Significance to Dental
Science, J.A.D.A. 33:151-180, 1946.
29

COMMONWEALTH
BOSTON 16, MASS.

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