Alveolar ridge resorption following tooth extraction

Jaime Pietrokovski, DAD., MS.,* and Maury Massler, D.D.S., MS.**

University of Illinois, College of Dentistry, Chicago, Ill.

F ollowing tooth extraction, the fundic part of the bony socket fills in with con-
nective tissue and bone, while the alveolar crest resorbs. After the wound heals and
is covered with epithelium, the edentulous ridge remains.l-lo An important question
is whether the center of the resulting residual ridge lies over the center of the origi-
nal dentulous ridge or has shifted towards the original lingual or labial plate. This
question is important to the prosthodontist who asks whether the artificial tooth
should be placed over the center of the edentulous ridge or whether the artificial
tooth should be placed more to the buccal or the lingual side of it in order to occupy
more accurately the position of the natural tooth.
On the basis of observations of dry skull specimens, Cryer’l stated that the
edentulous lower jaw lies external to and is wider than the upper jaw after all
teeth have been extracted. Rogers and Applebaum12 concluded from measurements
made in cadavers with dentulous and edentulous jaws that in the maxillae the
vertical height of the ridges had decreased, and the crest of the edentulous ridge
had shifted palatally after tooth extraction. They felt that in the mandible the
most extensive resorption of alveolar bone occurred on the superior surface of the
ridge and on the lingual surface of at least the posterior part of the ridge. Thus
they suggested that resorption of the labial plate in the maxillae results in a loss
of edentulous arch length and width, while, in the mandible, resorption of the
lingual plate increases the mandibular arch length and width so that the eden-
tulous maxillary arch comes to lie within the edentulous mandibular arch.
Tylman and Tylman13 wrote that, in the maxillae, the labial and buccal
alveolar plates resorb much faster than the palatal plates, while, in the mandible,
the amounts of bone resorbed at the lingual and labial plates are approximately
the same.
Swenson14 stated that after tooth extraction the alveolar process of the

Read before the Southeastern Academy of Prosthodontics in Williamsburg, Pa.

*Instructor, Department of Oral Rehabilitation. Present address: Hebrew University,
Hadassah School of Dental Medicine, Jerusalem, Israel.
**Assistant Dean for Postgraduate and Teacher Education and Professor, Department of
Pedodontics.

21
22 Pietrokouski and Masslrr

maxillae resorbs upward and inward to become progressively sruallcr because 01

the direction and inclination of the roots of the teeth. Consequently, the olcici
the edentulous maxillae, the smaller is the potential tooth-bearing area. He felt
the opposite to be true in the mandible. which inclines outward and bcconit’4
progressively wider with edrntulous sgc.
Most of the observations cited above were observations made by astut<
clinicians with long experience. However, an objective and quantitative study
to test these hypotheses could not be found.
The purpose of this investigation was to study the morphologic changes that
take place after a tooth is extracted, i.c., the patterns of edcntulous ridge forrna-
tion following tooth extractions in the maxiIlac and mandible.

MATERIALS AND METHODS

The amount of tissue lost after unilateral tooth extraction can bc mcasurcd
by comparing the edentulous ridge on one side with the tooth-bearing ridge on the
opposite side. This assumes that the left and the right halves of a jaw arc
symmetrical or almost symmetrical. Rased on this assumption, 149 dental casts
(72 maxillary and 77 mandibular) were selected for having one tooth missing on
one side. Measurement of the amount of alveolar resorption after tooth extraction
was obtained by comparing the edcntulous area with the opposite dentulous region
of the jaw (Fig. 1: A).
A duplicate plaster cast was prepared of each cast used in the study. ‘i’he
clinical crown of the homotypc tooth on the side opposite to the missing tooth
was removed with a sharp knife. The duplicate cast now had two homotypt:
“edcntulous” spaces- one from the “naturally” missing tooth, and the other arti-
ficially prepared (Fig. 1, B! .
The base of the cast was then ground parallel to the occlusal plane of the
remaining teeth. Two pencil lines were traced 10 mm. from the crest of the ridge
along the buccdl and lingual sides of the edentulous area with the help of a
partial denture surveyor. A similar marking was traced 10 mm. from the central
groove line of the removed clinical crown at the buccal and lingual sides of the
dentulous homotypc sidr. In this way, the edentulous ridge and the residual
alveolar ridge of the opposite side were traced at the same horizontal level,

Fig. 1
(A) An original cast. (B) A duplicated cast with crown removed from hotnotype of the
missing tooth (first molar on left ). The hone level is marked on the left and right.
plygTr ‘: Alveolar ridge resorption following tooth extraction 23
”

An image of the occlusal aspect of the prepared cast was projected on a

sheet of translucent tracing paper with an opaque object projector. The marked
lines showing both ridge prominences were then traced with a pencil on the
sheet of tracing paper. For further orientation, the occlusal surfaces of the adjacent
teeth were also drawn on the tracing paper (Fig. 2, A).
After this first tracing, the translucent paper was reversed and repositioned
over the unmoved projected image of the cast, so that the teeth neighboring the
edentulous area and the homotype tooth adjacent to the removed crown were
superimposed. With a pencil of a different color, the alveolar prominences of the
dentulous space were marked beside the traced lines of the edentulous space at the
buccal and at the lingual surfaces (Fig. 2, B) . The distances between the lines
marked by the two pencils of different colors showed the differences between the
alveolar prominence of the dentulous side and the residual ridge from the
edentulous side and, therefore, the amount of tissue lost from each aspect. A
linear measurement was made at the center of the mesiodistal diameter of the
cdentuIous space (Fig. 3).
This method thus measured the amount of buccal and lingual resorption of

Fig. 2
(,4) The first projection of the prepared cast on tracing paper. (B) A superimposition of the
left tracing on the right.

Fig. 3
The measurements were made at the center of the edentulous space. (A) The amount of
resorption on the palatal side. (B) The amount of resorption on the bucca1 side.
24 Pietrokovski and Mass&r

a partially edentulous region using the vpposite dentulous side of the jaw RN *I
basis for comparison.

FINDINGS
Control study. Thirty plaster casts obtained from the dental arches of patients
with complete natural dentitions were used to test the assumption that the right
and left sides of the dental arches are sufficiently alike and symmetrical for this
type of analysis. Following the previously described technique, the buccal and the
lingual prominences of the alveolar ridge surfaces of the left side were superim-
posed over the homotype alveolar surfaces of the right side. The superimposition
was very good, the contour of the left buccal and lingual ridges superimposing
almost precisely on the outline of the right buccal and lingual ridges. In a feM
casts, small differences were observed between the right and left sides. but these
differences were less than 1 mm., and well below the levels taken to be significant
in the subsequent study.
Experimental study. Table I shows the average amount of buccal and lingual
resorption in each tooth region after extraction. These data reveal the following
findings :
1. In the maxillae, the resorption of the buccal surfaces was significantly
greater than that of the palatal surfaces. There was a distinct shift of the center

Table I
Average amount of resorption after tooth extraction in different tooth areas”

Average amount of resorption

I----. (mm.1 --__ -_.-
Buccal surface 1 Lingual Surface ( Difi erence
Mandibular teeth
Central incisor 2.08 0.91 1.17
Lateral incisor 3.54 1.41 2.13
Canine 3.25 I .59 1.66
First premolar 3.45 I .40 2.05
Second premolar 3.28 0.75 2.5:1
First molar 4.69 2.79 I .90
Second moIar 4.30 3.00 I .:%I

Maxillary teeth Pnlatnl .su7face

Central incisor 3.03 1.46 I .57
Lateral incisor 3.47 0.86 2.61
Canine 3.33 1.91 I.42
First premolar 3.33 2.04 1.29
Second premolar 2.58 1.62 0.96
First molar 5.25 3.12 2.13
Second molar 4.10 2.93 1.07
*The amount of resorption was greater along the buccal surface than along the lingual
or palatal surface in every specimen examined, although the absolute amounts and differences
varied very widely. This caused a shift in the center of the edentulous ridge toward the
lingual or palatal side of the ridge with a concomitant decrease in arch length in the mandible
as well as the maxillae.
The number of specimens measured in each tooth series varied from 6 to 13.
The range (and standard deviation) was very wide (from 0 to twice the average).
Y2:EL
‘1’ Alveolar ridge resorption following tooth extraction 25

of the upper edentulous ridge toward the palate. This confirms the observations
made by others.
In the mandible, more resorption also occurred on the buccal than on the
lingual surfaces, in contrast to previous reports.
The greater amount of resorption along the buccal surface compared to the
lingual or palatal surface was true in almost every instance, in both the mandible
and in the maxillae. This consistency was striking.
2. The amount of buccal resorption was significantly greater in the molar
region than in the premolar and incisor regions. This difference was present in
both the maxillary and mandibular areas (Table I). The amount of resorption
in the incisor region was not significantly different from that in the premolar
regions.

DISCUSSION
Several techniques have been described to record the morphologic changes
in the residual ridge after tooth extractions. 16-10 All require special instruments
and a rather complicated procedure. The method described in this study requires
only an opaque object projector. The other instruments can be found in any
dental laboratory, thus making this technique available to any dentist interested
in the problem.
The pilot study was originally undertaken to test the accuracy of the technique
as well as to test the degree of symmetry of normal and edentulous arches. It is
an established concept that the human body in general and the human face in
particular are homotype complexes, the left and right sides being symmetrical and
similar although not perfectly identical.z0-25 Several authors, however, have stated
that the face and the dental arch are asymmetrical and that marked differences
can be detected between the hemijaws and/or hemifaces of the same individual.25l 27
The pilot study showed that it is possible to superimpose the right and left
side of an individual’s dental arches with an acceptable margin of accuracy. It
was concluded that the human dental arch (teeth and adjacent tissues) is a
symmetrical but not an identical complex, in most patients.
The superimposition of the reference points-the occlusal surfaces of the
adjacent teeth-was not always perfectly achieved. In such situations, the super-
imposition of the two hemijaws was an approximation. In these casts, tooth
migration toward the edentulous space could explain the lack of identity between
the two hemiarches.
An improvement in the present technique can be made by superimposing
and measuring several casts taken from the same patient before and after dental
extractions. With this revision, even small individual variations between the right
and left sides are eliminated, since the superimposition is made of the same struc-
tures at a different time. This technique should make possible the accurate dimen-
sional and positional changes to be measured following dental extractions.
The findings showed that in the maxillae the buccal plate was consistently
resorbed more than the palatal plate. The center of the edentulous maxillary
ridge therefore comes to lie very close to the original palatal crest of bone.
What was not expected was the finding that, in the mandible, the buccal
26 Pietrokouski and Ma.der

plate rather than the lingual plate was resorbed at a greater rate. This means that
the mandibular rdentulous arch also dccrcases in length and does ~rol increase
after tooth extraction. This is confirmed empirically by clinical observations. ‘1’h~
prosthodontist often finds it difficult to include a third molar in denturcts if As
artificial teeth arc aligned over the center of the edentulous ridge. It scans &at-
from these data that the natural teeth occupied a position well outside thrb cen~r-
of the edentulous ridges in both the mandible and the rnaxillae.

SUMMARY AND CONCLUSIONS

The amount of tissue resorption after tooth extraction was studied iu 149
plaster casts with single teeth missing through extraction by superimposing the
edentulous region over its homotype ridge with tepth present on the opposite side.
1. In a pilot study the left and the right halves of thirty casts obtained from
patients with complete natural dentitions were found to be symmetrical but not
identical to each other. The difference was very small and not significant to
this study.
2. The buccal plate in the maxilla was resorbed to a greater extent than the
palatal plate. The center of the edcntulous ridge. therefore, shifts to a position
closer to the palatal plate of bone, reducing the total arch length considerably.
3. The buccal plate in the mandible was resorbed more than the lingual plate.
The center of the edentulous ridge, therefore: also shifts lingually, so that the
arch length was also reduced in the edentulous mandible.
4. The amount of tissue resorption was significantly greater in the edentulous
molar region than in the incisor and premolar regions of both jaws.

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Volume 17 Alveolar ridge resorption following tooth extraction 27
Number 1

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