a-r--

M O R P H O L O G I CH
AL
A N G EI N
ST H E
DENTURE
BEARINGAREAFOLLOWING
THEEXTRACTION
OF MAXILLARYTEETH
h i t . d ? n t .J . , 1 9 7 4 , 1 1 6 . 2 2 5 .
Alveolar Process;Atrophy; Denture, complete.immediate:
Denture,complete,upperj Denture, partial, immediate:
D e n t u r e ,p a r t i a l .r c m o r a b l e ; M o u t h M u c o \ a : P a l a t e :
Too!h Extraction.

. . r ) . s .r.r . D . D .L, . D . s .
D A V I D M . W A T T I , p r r . D .F
P E T E R R . L I K E M A N I , s . o . s . .r . o . s .

Materials and methodsemployedin the-studyof posGextractionchangesin the maxillary denture

beari-ngarea are described. From an original sampleof 7l patients,25 were studiedot.i "
f..ioa
of 2[ years. The post-extraction dimensional changes are indicated in graphs, taUei-anA
diagrams.
-The changesin a sampleof 12 immediatedenturepatientsare comparedwith thosein a sample
of 10 patientswith denturesfitted after healing.
A s-tudyof spots tattooed,on the mucosaprior to extraction of teeth has made it possibleto
iden-tifythe remnant of the lingual gingival margin in the edentulousmouth.
The constancyof the pre-extractionmeasuremtntof the buccalJingualbreadth of the alveolar
processis noted, as is the usefulnessof this measurementas a biomletricguide for futl
d.nto."
construction.
rHE atrophy of the alveolar processafter the
lossof the teeth is a matter of common observation and it is apparent, from general clinical
e x p e r i e n c et.h a t t h e a m o u n t o f t h e a t r o p h i c
changein the residual alveolar ridges and-the
rate at which it takes place vaiies greatly
betwcenindividuals and between differeni parts
o f t h e s a m em o u t h .
Atthough the growth of the alveolar processeswith the eruption of the teeth and-the
development of the human jaws have been
carefully studied, the atrophic changes following the loss of teeth have ieceived siant attention. Nevertheless,
thesechangesare imDortant
to the practice of prosthetii dentistry. The
designof prosthesesto replace lost te;th and
resorbedalveolar ridges is largely determined
by Lheposition and amount of moroholosical
changein the denture bearing areas of the iaws
and, to a certain extent, thebptimum time for
fitting prosthesesdepends upon the rate of
cnangebeing minimal.
Reviewof the Literature
Lisowski (1944) used a tracing instrument to
study morphological changes following tooth
extraction,but his use of a face-bowto orientate
castswa-sa principal source of inaccuracy. He
observed.jn 10 patients, approximately2 mm
Duccaland 2 mm lingual loss of contour of the
re^srdual
alveolar ridge 2 months after extraction
o l m a 4 i l l a r yi n c i s o r sa n d c a n i n e s .
t;"n**"*

;-..,*",,u"

M A R C Hl 9 1 9 7 4

Dentistry, University of Edinburgh.

. Harper (1950) describedthe changesobserved

in.the. study_of 'several cases' birt gave no
indication of how many. He concludei (194g)
t h a t t h e i n c i s i v ep a p i l l a d i d n o t c h a n g ep o s i t i o n
up to 7 yearsafter tooth extraction,but'did nor
present e_ngughevidence to support this con_
clusion. More recent work has-shownthat the
position of the incisive papilla changes relative
to the vault of the palate after tooth extraction.
. Atwood (1957)in a radiographicstudy of 32
denture-wearingpatients estimated the com_
bined loss of alveolarridge height in the median
plane of maxilla and mandible varied from
0 . 3 7 m m t o 1 . 2 6m m p e r m o n t h b e f o r e t h e
insertion of denturesand from 0.1 to 0.21 mm
per month after insertion of the dentures.
Lam (1960) studied the resorption of anterior
maxillary tooth socketsin 3 patients and used
the standing posterior teeth to orientate succes_
sive casts. He found 2.7 mm loss in heisht of
re_sidualalveolar ridge I month after extriction
o t ' c e n t r a li n c i s o r sa n d 3 . 7 m m a f t e r 5 m o n t h s .
The corresponding means of loss in labial
contour were 3.2mm at I month and 4.1mm
at 5 months. He also observed that there was
no further change between the fifth and the
twelfth post-extraction months.
.Atkinson and Johnson (1962a and
6) des_
cribed an instrument for cast measuring and
supported their use of a palatal index fo*r cast
orientation by producing evidence that serial
cephalometric radiographs showed no change
in the posterior part of the vault of the palate

22s

9 y 9 ! 3 y e a r s . J o h n s o n( 1 9 6 3 ,1 9 6 4 a b, , c , 1 9 6 1 , rnade ol the post-extractionchangesfor each

1969a,b, 1970) measured serial casts up to j
tooth rernoved.
years. He found lessresorptionwhcrrimmediate
dentures were inserted than rvhcn denturcs rvere The Sample
f i t t e da t r h c e n d o f t h e p e r i o do f r a p i d r e s o r D r i o n Se.venty-onepetients were selected,the only
crrterion being that they requircclthe extraction
l 0 t o 2 0 x e e k sa f r e re i t r a c t i o n .
ol at lcast 4 maxillary. teeth. pre- .and p:lst_
Wictorin (1964), in a 3-year study of 77
'these
patients by cephalometric radiography. also extraction impressions \\,ere taken cif'
patients, rvho attended the clirric at varying
l o u n d l e s sr e s o r p t i o ni n c a s e sr v h e r ei m m e d i l t c
tirrcs, in diminishing numbers, as the siuc.tv
d e n l u r e su e r e f i t t e d .
progressed. It was p-rrticularly dillcult t;
Macgregor (1965) carried out a cross-section persuade
sonte of the paticnts to retrLrn for
study of the dimensionsof 351 dentulous and further
impressions after dcntures had becn
300 edentulous maxillary casts in order to fitted
and ntany of the seriesof caststerminated
design impression trays. Some indication of at that point;
as a result. onlv l5 n.ralesarrcll0
changesfollou'ing tooth loss can be obtained females
had adequateseriesof casts extenclins
by comparison of the mean neilsurements of over pcriods
of 2] years or more. The postl
his samples.
extraction intervals at u,hich thc casts werc
. Carlssonet al. (1967)reported on the reduc- made varied considerablybetrveenpatierrtsand
tion of the maxillary alveolar ridge under betrveendifferent groups of
extraCtions in the
immediate dentures in 38 patients. 6 months same patient. Nevertheless,
as far as possiblc,
after extraction, the cross-sectionalarea of the an attempt was made to obtain
casts at lbrtalveolar process in the median plane was nightly,intervalsfor thc first 2
months, at 3, o,
reduced by 23 per cent and by a further | | per 9 and l2 months after extraction
and, thereafter,
cent after 5 years. They observedthat afrer 2 a t 6 - m o n t h l yi n t e r v a l s .A
t o t a l o f 1 , 2 g 5v e r t i c a l
yearsthe reductionof the ridge from the oalatal section traces
were made of 206 casts froru 25
s i d ea n d . f r o m r h e r i d g e h e i g [ t p r o c e e d e dm o r e patients and comprise
lhe rnaterial fbr this
raprdly than trom the buccal side. Thev also study.
confirmed the stability of the radioeiaphic
All the teeth includcd in the sample ryere
shadow of the posterior part of the hard-paiate. extracted rvith forceps
and no bone ir.imrning
Maxillary ridge resorption has been studied or suturing rvas carried out. Teeth rvere
exover periods in excessof 7 years after extraction cluded fronr the study if they u,erefractured
or
(Atkinson and Johnson, l9j2; Tallgren, 1966, if there were surgicaldifficulties
involving bone
1 9 6 1 , 1 9 6 9 , 1 9 7 2 )T
. h e s es t u d i e ss h o w r h a t t h e trimming or suturing, or il there q'ere o-bvious
anterior vertical ridge height may continue to pre-extraction swellings or faults in the prereduce at a rate of 0.1 mrl a year or less, extractioncast. No ntcdian plane trace rvas
although in some casesit may apparentlycease. made rvhereone incisor rvasmissingbefor-cthe
start of the study as the remaiiing incisor
l\laterialsand Nlethods
tended to drift across the median plane and
The changesin the mucosal surfaceform of thc interceptthe plane of thc tracing.
denture-bearingarea of the upper jaw, following
All the impressionsu'ere taken in alginate
the extraction of teeth, rveie observecl in a and were cast immediately, using equal quar.rlample selected from patients attending the tities by rveightof plaster and Kaffri D. lZ ot
P,rosthodont ic Department of Fdi nburgh I)ental the patients were fitted with full or partial
Hospital. Impressionswere taken beforeand at immediate denturesand l3 had denturcs fittcd
intervals after the extraction of teeth. Vertical at periods varying from 14 to 52 rveeksafter
section traces of the pre- and post-extraction extraction. All the dcntures were made ivith
castswere made as follows:
labial flangesand the immediatc denturesdid
(l).Tracings in sagittal planes: through the not extendinto the extractionrvounds. In ordcr
median plane and central incisors.
to minimise any changeproduced by the dcn(2) Tracingsin coronal planes:through canincs, tures, particular attention was paid to their
first and second premolars, first, sEcond and occlusalbalanceand fit, which rverecheckedat
every visit. Patierrtswere requestedto leave
third molars.
In each series of casts, tracings were made their denturesout at niqht. and rhat this rvas
only where teeth were present at the com- being done rvaschecked-byquestioningat elch
mencemnt of the study. The post-extraction v i s i t .
t r a c e sw e r e s u p e r i m p o s e idn t u r n o n t h e e q u i _ The'Stable Area of the Palate'
valent pre-extraction trace and measurements It rvas essentialthat the casts
were mounted on
226

RRITISTI DENTAL JOI-IRNAI

--r4a
s

1,

*ilt

I
I

,:

the .tracing instrument as nearly as possible in

an identical manner. Differences of anteroposterior or lateral tilt would result in the
tracing point passing over parts of the serial
casts which were not equivalent to each other,
and would invalidate any conclusions drawn
from a comparison of the traces. The accuracy
of the mounting of the casts was therefore
fundamental to the study and the method used
was based on radiographic evidence that little
change took place in the vault of the hard palate
during the period of investigation.
There was, however, no evidence for the
stability of the mucosal surface covering the
palate; a careful study was therefore made of
the 25 pre-extraction and 181 post-extraction
casts of this study, together with 46 pre-extraction and 138 post-extraction casts from incomplete series. These 7l series of casts were
studied with a hand lens. At least 4 points in the
mucosal pattern which could be clearly identified throughout each serieswere marked on each
cast in an area bounded anteriorly bv the third
pair of rugre, laterally by sagittat ptaires l0 mm
from the mid-line, and posteriorly by a coronal
plane 5 mm anterior to the posterior border of
the hard palate. Comparative measurements
were then made between the points on the casts
of each series. On everv cast of each series at
Ieast 4 such points could be identified which
maintained their relationship to within 0.3 mm.
This was accepted as evidence of the relative
stability of the form of the mucosal surface in
this area of the palate.
_ It,is recognised that stability of any part of
the human body is only a relative value and it
is not implied tiat changes were totally absent
in the 'stable area' of the palate but rather that
the changes over the 2! y,iars period of the first
part of this study were negligible when compared with those of the alveolar ridges, so that
valid measurements of morphological changes
following tooth extraction- could be made
relative to this area. The vertical tracings were
then arranged to cross this stable area ii every
casl-of a series, so that, by superimposing the
stable portions of the traces, changes which
occurred in the other parts could be measured.
The Refererce Planes
In order to position the tracings of each series'
accurately, each cast was considered to be
divided by two imaginary planes which intersected each other at right angles (fig. l). The
pldrtes selected were the 'median' plane, as
defined by one anterior and one posteiior point
on the median raphe. and a coronal 'reference'
plane, which interiected the median plane within
MARCH19 1974

Frc. l.-The median sagittal and referenceplanes.

The M and R pointsareon the stablepart of the palate.
the stable arca at a point (R) near the medial
ends ofthe third and fourth pairs ofrugr.
On each sagittal trace, the point at which it
intersected the reference plane was indicated by
a vertical line (R line) and on each coronal trace
the intersection with the median plane was
indicated by a similar vertical line (M line). The
R point, which representsthe intersection of the
R and M planes on the surface of the cast, was
selected by finding on the median raphe near
the ruga a characteristic detail which was easily
identifiable on all the casts of a series. The
point was confirmed by a constant linear
relationship to other defined points within the
stable area. The posterior M point was similarly placed on a permanent surface configuration on the raphe near the posterior border of
the hard palate not less than 5'mm anterior to
the vibrating line. This point, together with the
R point, defined the median plane.
Mounting the Casts
Each of the casts to be traced was mounted on
a 9 cm square Perspex base with impression
plaster. A mounting jig with four adjustable
pointers was used (fig. 2).'The pre-extraction

Frc. 2.-The jig used for mounting seriesof casts to an

identical orientation on machined Perspex bases.

227

cast was set up with the occlusal plane horizorLlll. The posterior pointer of the jig was
positioned on the M point, the anterior-p-ointer
on the R point and fhe cast securedto'the jig
by an elastic band passing undbrneath it. Two
lateral pointers, placed 5 irm either side of the
mid-line, contacied the surface of the palate
within the stable area to maintain the position
of the cast. From this position, the iast was
Iowered into a mix of impression plaster on the
Perspex base. The level of each cast was
identical as it was determined by a stop on the
mounting jig. Each Perspex base was oiientated
in an identical manner by a set-squareclamped
to the table of the instrument. The side of ihe
base.was set parallel to the median plane. Each
of the casts in a series was positioned on the
jig in turn and secured to d separate perspex
base.
The Tracing Instrament (Figure 3)
The base of the instrument for making the
tracings was an engineer's surface tablE. A
vertical steel plate, the paper holder, was bolted
to the back of the table. The traces were made
upon papers which were fastened to this holder
by button magnets. The main part of the instrument comprised a double jointed, counterpoised surveying arm clamped to the right side
of the table. This arm mov-edin a plane*parallel
to the-surface of the paper holder. At fhe free
end of_the surveying drm, a cranked rod passed
through two bearings and rotated about a
horizontal axis which remained pemendicular
lo the surface of the tracing paper no matter
what the _position of the suiveying arm. A
stylus with a rounded steel point oT 0.75 mm
Jiameter was fixed to the iront end of the
;ranked rod in such a manner that the point lay

tc. 3.-The tracing instrument. A tracing being made

in the coronal plane.

228

exactly-in the axis of rotatiol of the,rod. Thus,

the stylus_couldbe rotated through 360., moved
up and down, and from side to side, but re_
mained in a vertical plane parallel to and 20 cm
Irom tne traclng paper.
A pen of the type used. in barographs was
mounted on a spring-loaded hinged bar attached
to the other end of the surveying arm. The
spring held lhe pen.away from the tracing paper
but pressureon a button on the right or oir a
lever on the left of the table activated push rods
which brought the pen into contact with the
paper in the same axis as the stylus tip when a
trace was made.
The casts were positioned on the table by a
steel bevel which located the same corner of ihe
Perspex base as had entered the set square on
the mounting instrument. The short arm of the
bevel was held in close contact with the left side
of the table where it registered on a millimetre
scale and guided the whole back or forth in a
path normal to the paper holder.
The traces from the first cast of a series were
made-on millimetre-sqr,eregraph paper. They
provided thc baselinesfrom which post-extraction changes were measured. Subsequent traces
from the post-extraction casts were made on
tracing paper so that they might be superimposed on the equivalentpre-extraction traces.
After tracing the median plane and before
moving the cast or the paper, the vertical R line
was marked to indicate the position of the reference.plane. The cast and the locating bevel
together were advanced to bring each-of the
central incisors in turn into tho plane of the
tracing point. The position of these traces was
noted on the millimetre scale and the R line
marked to indicate the position of the reference
plane on both of these tracings.
The cast was then turned through a right
angle so that the tracing point m-oved in a
coronal plane and tracings were made through
each of ihe posterior teelh in turn, their poiitions again being noted on the millimetre scale.
The M line was marked on each trace in the
same way as the R line on each of the sagittal
tracings. Only the lateral incisors were totally
excluded from this investigation, as sagittal
tracings of these teeth did not cross the stable
area of the palate. Coronal traces anterior to
the R plane were assumed to fall entirely in an
area subject to change and were superimposed
by relerenceto the vertical change indicated on
the median sagittal plane trace at the point
where it was crossedby the coronal tracing.
Repetitive tracing of the pre-extraction cast
was avoided by superimposing the post-extracBRITISH DENTAL

JOURNAL

tion traces in turn on thc pre-extraction trace

and making direct _contactphotographs. Measurements \{ere made on the dev..loped negatives

using a Brinell microscopecalibratedin tenths

of a millimetre. The poJitions of measuremint
are shownin figurc4a, b, c.

_
Ftc'

4'-Measurement of
,the traces: a, sagittal ptane; Q, coronal plane anterior to the stable area of the palate;
c, coronat ptane crossine thestabte are:a;t ih; i;dt.: iti:i;;iiffii,iiiii'iilr*"rnents:
RH ridge height; BLB
bucco-linguat breadth: IpB,}]ll1t-""r
b;fiih:-ilrj
;;6t3f ;,6td:-Foiij"ii'.""tion
measurements:B (u, m, l)
09cqal:-upper, middle a-nd
mquurements; ihe mein
.lower
ot the lingual gingival margin;
p palitat ttringi, iruniu.tr. oi irtiiE rc'.t o"*o-as buccat change;-LV verticat change
or sagittal in the plane of the tracing; MV median vertical.

MARCH19 1974

229

Errors
Calibration exoeriments were conducted to
investigatethe 6rrors from variationsin mounting the castsand superimposingthe traces. The
mean error of the former variedbetw'cen0'2 mm
and 0'5 mm, depending on the position of
measurenent. The mean errors of superimposition varied bet*.een0'1 and 0'3 mm.
The post-extraction intervals at tvhich the
traces were made varied from patient to patient
and, in order to comparethem, it was neccssary
to construct graphs of post-extractionchange
plotted against time. Graphs of buccal change,
lingual vertical, and palatal change, rvere made
for every region of the mouth traced in each
I'Aal E I.

nrm

Nledian
plane
(n -- 18)

Ir

(n
t

.37)

patient. The changesover 2] years at each ol

the 8 regions traccd are shown in Tables I, ll
and III and are illustratedin tigures5, 6 and 7.
These diagrams were made from the traccs ol
the patient rvhose measurenlentswerc nearest
to the mean for the rvhole sample. Thc traces
were alteredexactly to coincidervith the means
at the positions of measuremcnt.

-I

RACrs rN MFDIAN PLANE AND THlroucH

I'inrc in ||?eks since\l! e.Ylrttction

8
1
2
1
6
2
6

nlnr

nlnt

m4l

illnl

n|Dl

nltlr

ntil

nt|il

1.60

1.85

2.20

2 40

2.80

1.05

3 20

3.35

3 50

360

0 80

0.95

l.l5

1 30

1.60

I 85
'1.' 70

l.9i

2.05

2 20

2.30

8.20

8 65

9 00

935

2 75

2 85

3.00

325

2.90

3 00

190

2.90

350

3.90

505

580

680

0.60

0 95

1.25

1 55

1.95

2.20

2.50

Il0

142

160

1.70

2 28

2 48

2.65

2.78

6.05

1.92
' 1.35

2 00

5.40

8 05

9'00

9 85

l0 30

l0 75

AVLRACF Posr-ExTRACTIoN CsaNcrs

Dlln

rN CORONAL TRACES rHRoucH

77

(n-.9
t = .1 . 1 )

nlnt

2 60

3.00

CANINtis AND PRIMOLARS

52

230

10.1

130

ltxtl

nlll1

ililt

tnill

tltIl

3 55

3.85

4.25

4.65

4 U0

5.10

5.30

5.6-s

3.10

3 25

1.50

3.70

1.85

3.90

3 9_5

0 90

0.95

I 15

1.30

r.35

1.45

1.50

1.55

230

Lingual
vertical
Median
vettrcal
Buccal

1.40

2.20

025

050

0 60

0 75

0 50

0.85

I.20

I.45

I 90

2 20

2.65

2 85

2.90

1 10

3.20

3 35

260

2.95

315

3.25

3.10

3.50

3 60

11 . 9 0

Lingual
vertical
Transverse
palatal
Buccal

2.55

080

135

I70

200

235

305

435

5.30

6.20

7 60

8 85

10.45

I1 05

il 35

12.25

r 2 50

I 65

2.15

2.45

2.85

3'00

315

.330

3.40

3 55

2.35

2.70
't.25

2 9s

3.40

3.55

3 65

3.75

3.85

8.05

9 45

10.10

1t 1l

0'60

1 00

1 35

2.t0
Lingual
l'20
1 65
vertical
2'75
4 45
5.55
Transverse
palatal
n:number of patients in sample.
t : n u m b e ro f t e e t h i n s a m p l e .

6 35

Posr-ExTRACTIoN CHANcEs IN CoRoNAL TRAcEs rHRolrcH

Tine in wcekssinceexlra.lion
8
1
2
1
6
2
mD1

52

78

10,1

130

3 20

3.45

3.75

3 95

4.10

4.20

29O
'77O

3l0

320

340

345

805

840

925

945

'130

445

470

'1.90

5.00

lnnl

2 30

2 60

2.80

085

1'45

190

210

230

245

27o

3.05

,140

495

535

585

625

710

100

180

215

295

3,15

365

405

Lingual
vert lcal
Transverse
p a l a t aI
buccal

mm

buccal

120

165

200

225

250

265

280

29O

295

315

330

340

390

4','O

5.25

570

645

705

795

860

890

915

935

1025

170

2'35

260

280

295

310

340

355

365

380

400

410

2.00

22O

230

250

255

260

2'7O

280

285

685

760

805

905

975

1060

185
Linsual
145
165
vertical
600
Transverse 395
505
palatal
n:number of patients in sampl
t : n u m b e r o f t e e t hi n s a m p l e ,

n
X

THE l\{oLARs

llolt

illnl

ttnl

3 95
ll 90

39

2.t0

1.10

11..15 11.70

(_

t.15

Buccal

Lingual
vert ical
Transverse

2.' 15

palJ l f,l

E 8
(n-.8
r- 12)

78

l/lnl

ttm

Frc'.5.sagittal
rlonths

I I l0

150

nlm

8
ll)

nttt

2.65

Buccal

2
(n:
r

ll0

1 25

TABLE III.-AVERAGE

6 6

10.1
nlnr

0 65

nlnl

(n-.9
t:16)

tnnt

0 35

Titne in ||ceks siilaeettraction

6
8
1
2
1
6
2

(n: l5
16)
t

1ll

78

0 80

TABLF Il.

4l{

52

Lingual
vertrcal
Sagittal
palatal
Buccal

Sagittal
3.30
4 70
palataI
n : number of patients in sample.
t nunber ol tecth in sample,

(n-15
r- 28)

39

Buccal

Linsual
vertical

Observationsand Discussion
( I ) Rate of Change
For every tooth extracted the amount of change
of contour was plotted against time and 3il
graphs were constructed to enable post-extraction changesto be studied. In every case,a

AVERA(jE Posr-EXtRACTtoN CHANCES IN SAcrrrAL

'.+

ll20

ll4

1l'65

FrLi. t
canine
and 3(

faplc

tion,
decrt
extra
averi
b,u"el

asp
yean
\11

BRITISH DI]NTAL JOURNAL

--

Irrc.. 5.-Average changes in median sagittal plane an<l

sagittal plane through central incisor 1, 3, 6, f2, and 3O
months post-extraction.

Ftc. 7.-Average_ changes in coronal planes through

f i r s t m o l a r , s e c o n dm o l a r a n d t h i r d m o l a i l , 3 , 6 , 1 2 , a ; d
30 months post-extraction.

The figures may be shown by the followirrg

approximate modal values:
40 per cent by the end of the first
post-extraction month ;
65 per cent by the end of the third
post-extraction month;
80 per cent by the end of the sixth
post-extraction month ;
90 per cent by the end of the twelfth
post-extraction month.
, The averagepost-extraction changesover the
8 regions appeared to be slightly less in males
than in females,but in view of the small samole
and the large range of the observedchangesihe
differencewas not of importance.

Ftc. 6.-Average changes in coronal planes through

caninc^,first premolar and second premolar 1, 3, 6, i2,
rrnd 30 months post-exlraction.

rapid change was observed shortly after extraction, and there was a general trend towards a
decrease in the rate of change as the Dostextraction time increased. An a-ssessment
of the
averagerate of change in the sampleswas made
by expressingthe averagechangesin each region
as perc^entagesof the average changes at 2$
years after extraction.
MARCFI19 1974

(2) Main Dimensional Changes

(a) Two-and-a-half years after extraction of the
teeth_,the ayeragebuccal change in the sample
of 25 patientswas approximately3.5 mm in ihe
median plane. central incisor and premolar
traces,and 4 to 5 mm in the molar trates.
(6) Th9 average vertical loss of height (lingual
vertical change) 2! years after extraction was
between 3 and 4 mm in 7 of the 8 resions
traced, but in the median plane the meaiurement was 2.3 mm. The smaller measurementin
the median plane rvas chiefly due to absenceof
gingival margin collapse in the region and also
to the forward movement of the incisive papilla
.presenting a change in contour at the p-osftion
oI measurement.
(c) The atrophy of the residual ridges affected
the shape of the palate and its contour in a
given plane widened as the atrophy of the
ridges progressed. The area of the palate

231

affected by change extended towards the centre

of the palate until only a relatively small
median area remained unchanged 21, years
after the extraction of the teeth. On average,
this area was roughly boundcd by a line drawn
on the surface of the palate about I cm from
the lingual gingival margins (flg. 8.)

A series of tracings through a first uppsl

molar where the denture was fitted t0 w-eiks
after extraction, and through a first premolar
following the fitting of an immediate denture
ui" rho#n in figures"9and 10. tn the casedttei

.l-v

.rv
,T-v
Frc. 8.-The part of the palate which remained stable
over the 212-yearperiod of the study is indicated by the
stippled area on the diagram.

At the end o[ 2! years study, the palatal

change was still progressing slowly. Further
diminution of the stable area was, therefore, to
be expectedin studies covering a longer period.

1 week

6 wks

10 wks

/T-'\j

18 wks

rl\J

20 wks

/r-v
/r-v

28 wl(s

(3) Gingival Margin Collapse

43 wks
General observationsshowed that in every case
the buccal and lingual gingival margins collapsed towards the socketswhen the teeth were
exlracted. This was reflected by a dip in the
60 wks
graph of lingual vertical change shortly after
proceeded
change
extraction and thereafter the
more slowly (see fig. l2). In the median plane
there was naturally no such collapse and the
158wks
first part of the graph showed a more gentle
slope than in other regions of the same mouth.
A number of the tooth socketsstudiedshowed Frc. 9.-seriesof tracingsthroughthe iS regionof one
wasfittedat l6 weekspost-extraca surface concavity when they were first healed patient.Thedenture
at that
but as the healing progressed the concavity iion andit canbeseenthat thesurfaceconcavity
at 158weeks.
became less obvious. This was chiefly due to timeis still in evidence
shrinkage of the margins but partly due to
l6 weeksalter extraction.the depressedscar of
proliferative change within it.
the extraction wound was preservedby the form
of the denture throughout the 3-year period. In
(4) Efect of Dentures
the immediate denture case, the ridge had been
If denturesare to be fitted a short time after the smoothed on the cast and it can be seenthat the
extraction of teeth, it is advisable to fill the smooth contour was preserved throughout the
depressionson the cast with plaster so as.not period of study.
to inhibit any proliferative change. In those
patients who were fitted with immediate den- (5) Immediate Dentures
tures, the castswere trimmed so that there were When removing teeth from the cast before
making immediate dentures they should be cut
no depressionsand a smoother ridge resulted.

F r c . 1 0 . -'I
patient.
to the Pl
socketing.

/T\J
/I-YJ

232

BRITISH DENTAL JOURNAL

Frc. ll.plaster ter

constructl
interrupt(

off at tl
catedin
portion
the con
gum fitt
with un
bone. I
ing denl

L"+-r

A s a m p l e o f l 2 i m n r e d i a t ed e n t u r e p a t i e n t s
was comptred with a sampleof l0 patientswith
dentures fitted after heaiing. The amount of
buccaland vcrtical cha.ngcin the central incisor
legion is illustrated in the graphs in figure 12.
4 wks
The stippledareas.representlhe
rangeoichange
observedin the whole sample. ThJcontinuous
lines represent the change in patients with
immediate dentures and ihe intcrrupted lines
8 wks
t h e c h a n g e si n p a t i e n t sw i t h d e n t u r e sf i t t e da f t e r
h c a l i n g . l t c a n b e s e e nt h a t s l i g h t l yl e s sc h a n g e
t o o k p l a c e i n t h e p a t i e n t sw i t h i m m e d i a t ed e i _
tures, but statistical tests indicated that the
differencewas not significant. It can be seen
12 wks
that the difference between the immediate
denture patients and the ordinary denture
patients diminished with time, so that. at 2l
years, the differencewas completelynegligible.
27 wks
(6) Changes in Incisive Papilta and Ruge
A changein the position of the incisivepanilla
'*as
relative to the stable area of the palate
44 wks
o b s e r v e di n e v e r yc a s ef o l l o w i n g t h e e x t r a c t i o n
o f t h e m a x i l l a r yc e n t r a li n c i s o r s - a n d
c h a n g c si n
the shape of the prpilla were also fouid to
accompanythc loss of theseteeth.
142 wks
. On average.the papilla moved forward about
1 . 6m m ( r a n g e 0 . 6 t o 2 . 7 m m ) a n d u D w a r d s
about 2.3 mm (range 1.3 to 4.0 mm). This
Frc..10.-Seriesof tracingsthroughthe {l regionof one movemetrt of the papilla has an
important
pauenr. I ne smooth contour of the ridge
is attributed lmpttcatlon. As rcsorption proceeds,the rela_
-incisive
to .the provision of an immediate dinture *iitrour
tions.hipbetween the
ptpilla and the
socketing.
incisive fossa changes. Thc foisa tends to
occupy a.more posterior position as the bone
resorbswhilethe papilla movesforwards. Thus,
t h e l o s s at e n d st o l i e p o s t e r i o rt o t h e p r p i l l a i n
the edentulousmouth.
T h e i n c i s i v ep r p i l l a p r o v i d e sa r o u s h g u i d e
t o t h e p o s i r i o no f t h e n r a x i l l a r yc a n i n c i . I i i t h e
de.ntulous-mouth, a coronai plane through the
middle of the papilla generally passesth"rough
the canrne crowns but after the teeth are lost
the caninesshould be locatedin a coronal plane
passing through the posterior border oi the
papilla. The so-called canine eminence in the
Frc. Il.-Diagram illustratingmethod of removal of
edentulous mouth often lies distal to the true
plasterteeth lrom the cast prior to immediatedenture
canine position. particularly where there has
mnstructio.n..The cast is trimmed as indicated by the been
much resorption. It is formed by the
rnterruptedlines.
buttress of bone between the larger canine
socket anteriorly and the sma-llerfirs-l oremolar
off at the level of the gingival papille as indi_
socketposteriorly.
cated in the.diagram (fig. I | ) anii fhe remaining
. Changes in the position and shape of the
portion of the tooth should be carved to follow
rugre followed the extraction of anteiior teeth.
the contour of the ridge. Cutting sockets and
The g.reatest
changetook placc in the first pair
gum fitting the teeth usually resu-lts in a
ridge
ol 'pnmary rugie'(Lysell1
. 9 5 5 )w
, h i c ha p p e a r e d
witlr. uneven thickness of mucosa overlying t[e
to be carried forward and upwards *iitr tt e
bone. This provides poor support for iuiEeea_ papilla
by the hinge like .movement of the
rng dentures.
mucosa concomitant with the underlying bony
M A R C H1 9 1 9 7 4
2 weeks

t.+r

L-+J

W
W

r.:.?-r:

MARGIN
RANGE & AVERAGEVERTICAL POST'EXTMCTION CHANGES AT LINGUAL G!'IG[VAIN SAGTTTAL TRACES THROUGH !IL.
(r) mrrevrs

HEALING
wrIH |MMED|ATE DENTURES n=12 (e) PATTENTSWTH DENTURES FITTED AFTER
TIME IN WEEKS SINCE EXTRACTION OF
3

III

E - l

(rz
I-.

RANG E A/ERAG zuCCAL POST.EXTRACTION CHANGES IN SAGITTAL TRACES THRO{JGH IIL.

(A) hT|ENTS MTH |MMEDTATE DENTURESn-r2 (B) PATTENTSWrTH DENTLRES FrTED AFTER HEALING n.lo.
T|ME rN WEEKS Sll.|CE EXTRACTIONOF lll.
t

E
A
U

tAw

o
z
U

Frc. 12.-Comparison of lingual vertical and buccal changein sagittal planes through central
incisorsin natients with immediatedenturesand denturesfitted after healing of sockets. The
stippled areas represent the range of change observed

change. A similar forward and upwards movement of the secondpair of ruge also occurred,
but later than in the case of the first pair. The
change, hou'ever, was usually evideirt by the
26th post-extraction week. In some cases the
lateral ends of the third and fourth pairs of
ruge wore observed to move upwards an.d
laterally, especially when the ruga were long.
These movements of the rugr are significant,
as changes in their position under dentures
leads to pressure upon them. This causes
flattening of the rugre and occasionallypatients
experiencediscomfort in the ruge area. The
first and second pairs of ruge are chiefly
aft-ected.
In cases of extreme resorption, the residual
alveolar ridge disappears entirely and the soft
flabby ridge which is left does not comprise any
alveolar tissue but is composed entirely of the
soft tissue of the palate. The ruge may be seen
forming transverse ridges across the anterior
part of this so-called 'soft residual alveolar
r i d g e ' ( f i g .1 3 ) .
(7) Tattoo Spot Study
In 8 patients of the sample, a tattoo spot was
placed near the gingival margin on the buccal
and lingual side of each tooth before extraction.
A total of 110 spots were tattooed. The movements of the tattoo soots indicated that the
234

Frc. i4
to4iy
cast tn(
and th
indicatr
require
;t is r

ever b
iras ta
e\trac
therefi
and re
positir

Frc. l3.-L,xtremeresorptionof the maxillain which

the rugrcmay be seencrossingthe residualridgewhich
entirelyof formerpalataltissue.
is norvcomposed
sreatestreduction in mucosal surface area took
ilace in the areas of the extraction wounds.
Scar tissue contraction in these areas may have
contributed to the observed changes in the
positions of the rugre.
It was evident, from the study oftattoo spots'
that the remnant of the lingual gingival rnargins
could be easily identified on edentulous casts
(fig. 1a). Itwas also evident from pre-extraction
measurements(BLB, fig. 4) in this and another
study (Watt et a|.,1961) that the betweenpatient
variation of alveolar'breadth at each tooth
position was relatively small (Table IV)' Thus'
ERrrrsu DENTAI- JOURNAL

ij
.ii
:
;
J

ACKN(

\Ye ar

TABLE IV.-ANALysrs

oF MEAsuREMENTs oF HoRIzoNTAL

,,,,,,,,;,;

BREADI

o:;;' :ii:li;:[::il'i3'lH:

central incisorsagittal

oR

!fi:i?::,T,:?'"..."",
.i::#jT#iJlf
:nf,X'""
g+ruj{145 coronalsectioni
rrrst morarcoron"t

ii::t*T,?'i:j:j:tit
'Molai
iegton'combined
EZIZScoronal sections

FR.MrHELtxcuarcrNG,vAL
MARGTNS
?'l If" S.I^Y,'3.?],'J":,::$':
ro

data

ip
;3
119

j!

45
rc6

Min
*,\

Max
n:m_

x
mm

SO
mm

;! lii
f i ?Bl
;:i l3:i i3B lli
'i 3

.q !

13 6

10.3

1.27

lt.O

1.37

74

i19 I?2
??i
ic o
lo.t
1.33

7.g

14.3

who made the instrumentswhich were used

this study and who provided *""f, t".[ni"ufin
assistance.
We alsowishto-thantMia.liuot"r,
R.
Renton
and Miss M. il;;;;?Jr'th"
Y.
illrrstrations,and the many otherun"mOeis
of
staff of the University of fOinUuig-fr*f,o i,uu"
rn somemeasure
assisted
us in thiiwork.
REFERENCES
Atkinson. H. F.. and

(t962a) Aust. dent.J.,7.3t0.

-'".
LoJljl^.gn,
( l 9 - 6 2 bAtI.u s t -d e n t -J . , j . f S f
(1972) eut. dent. J.,17',140',. " - " '
Atwood, D. A. (1957)J, prosth. Dent.,j,544.
tlttii:."'
E., Rognarson, N., and Astrand, p. (1967)
oclont. 7.,

Frc..,l4.-Ser-ial castsshowing tattoo spot positions

up
to 4$ years after tooth extraction. The arrow in
castrndicaresthe remnantof the linguil gin;iv;i tfr" tu.t
and the measurementsB.r-.r. on first and ;a;;rn,
last casts
indicate-the toss of tissue ana nence irr! irri#i.ri?tr,
required on the edentulous cast.

it is possible to estimate more accurately than

eyer before the amount of buccal chanee'wiiich
has taken place in patients fo, *t o--no
o."extractlon casts are available. Dentures ^can
therefore be designed to restore the lost tissues
anc.replace the teeth more nearly in their correct
posrtlons(Watt, 1970).

Harper, R..N. (.19_48)

J. dent. Res.,27,661.
(t950) Dent. Items,72, i!2i.
J o h n s o nK
, . ( 1 . 9 6 3 \ . A u sdt -c n t .J . , g . 4 2 g .
( . ! l y . q ) A u s t . d c n t .J . , 9 , 6 .
l t v b 4 b ) A u s t -d e n t .J . , 9 , 1 2 7 .
jiz.
.{!le-!ct Ausr. dent. t.,g,
t,179!.Aust. dent. J-,"12, 152.
\,t:9t^qA
l u s t . d e n t .J . , 1 4 , 2 4 1 .
t.le^9??tAust. dcn,.
'-......._(1970) Aust. det. J.,14,3j0.
t., tS,'CAl.'
Lam, R. V. (196O)J. prosth. Dent,,tO.25.
Lisowski. C:S. (1944) A Compararive Study
of the Resorption of
A,iveotarRidge.Tissue under'tmmeai"ii-o'.ri".lr.
v.ii.S."it"rir,
Northwestern University, Chicago.
Lysell, L. (1955) Acta odont. scand.,13,6,
suppl. lg.
Macgregor, A._ R. (1965) The Size and Form
of Dentulous and

,li:i,,,.rt:i"::rff
,;f
Ff,:fi
i..nr,,jl:o*.ien"i'rii,i.!',',iti?,uv..

Taffgren, A..^(_1966\
Acta odont. scand.,24. 195.
\rto t ) Actq odont. scand.,24, 563.
t !e^99^t
4fra odont. scand., 27, 5i9.
\ t 9 t z t J . p r o s r h .D e n t . , 2 1 , 1 2 0 .
WlIl;^?:,Y.-q?gO) Morphologicatchangesin
the denture bearins area
ormaxillarv ieeth. Ptr.D. itrerii-trni"?i.tty
i?'f}'Jf"lli.t-"action
(1970) Anglo-coruin.dent. Soc. Newslerter.23.
l0-

ACKNOWLEDGMENTS

We are particularly indebted to Mr J. Copland

(r-.L),#:'rdij

c' M" andAdenubi'

i'-ij."irb61i'i:"*. uoe.

Wicroritr. L. (1964) Acta radiol. (Stockh.),228. 1.

\uuuuu\lNuu
MARCHlg 1974

235