Journal of Oral Rehabilitation 2001 28; 267-272

Position of the teeth on the edentulous atrophic maxilla

L. V. J . LASSI LA*, E. KLEMETTI t 6 V. P. LASSI LA* *Institute of Dentistry and Biomaterials Research,
University of Turku, Finland, iFaculty of Dentistry, McGill University, Montreal, Canada and *Department of Prosthetics and Stomatognathic
Physiology, University of Kuopio, Finland
SUMMARY For prosthetic treatment of strongly at-
rophic alveolar wall, some biometric methods have
been developed. The measurements taken from plas-
ter cast models of 230 edentulous, average 29.9 years,
and 125 dentulous post-menopausal women were
correlated. In the edentulous maxilla the sagittal
position of canine teeth can be determined by the oral
edge of incisive papilla. The transverse position of
canine teeth was on the outer edge of the alveolar wall
because of the extensive loss of buccal alveolar bone.
On the incisor area the facial surfaces of the central
incisors were determined by the oral edge of incisive
papilla and the distance was about twice the length
of the papilla. The sagittal position of the first premo-
lars was one-third and the first molars two-thirds the
length of the palate from the plane of the labial edge
of incisive papilla. The transverse position of the
Introduction
Atrophy of the alveolar process after loss of teeth
progresses with variable speed, as has been found by
many researchers (Carlsson Bergman & Hedegird,
1967; Tallgren, 1972; Watt & Likeman, 1974). The
reasons for the speed of resorption can be related to the
characteristics of the individual such as: age, certain
systemic diseases, and also to poor fitting dentures
(Kelly, 1972; Von Wowern & Stoltze, 1979, 1980;
Tallgren et al., 1980; Ettinger & Beck, 1983; Kalk & Baat,
1989; Kribbs et al., 1990; Klemetti 6 Vainio, 1994).
Very valuable information about alveolar resorption
has been obtained from longitudinal studies of edentu-
lous patients (Carlsson, Thilander 6 Hedegird, 1967;
Tallgren, 1967; Atwood 6 Coy, 1971; Douglass et al.,
1993). The methods used in these investigations have
premolars and molars was determined by the scar-
line, which is a cord-like elevation or track on the
alveolar mucosa after extractions of the teeth. Ac-
cording to the comparative method, the position of
the scar-line differed from the lingual gingival margin
line and was situated about half breadth of the tooth
in a buccal direction from it. The transverse position
of premolar and molar in the edentulous maxilla is
about the middle of the scar-line in a facio-buccal
direction. In the setting of the artificial teeth, the
facial surfaces of these teeth should be on average
5-0-6.0 mm sideways from the scar-line, whilst the
total bilateral breadth of the alveolar wall in the
sulcus area was on average 1-0-2.0 mm larger.
KEYWORDS alveolaratrophy, biometric denture de-
sign
been X-ray cephalometric tracing or pantomographic
methods. Other researchers have determined the corre-
lation of the mineral status in the skeleton with the
density of alveolar bone (Humphries Devlin & Wor-
thington, 1989; Von Wowern & Kollerup, 1992; Hirai et
al., 1993; Klemetti & Vainio, 1993; Klemetti etal., 1993;
Klemetti, Kroger & Lassila, 1997). To facilitate the
clinical estimation of the amount of alveolar bone loss,
Likeman &Watt, 1974, Watt 6 Likeman, 1974 and Watt
6 McGregor, 1986 have presented some guides, such as
the incisive papilla and the remnant of the lingual
gingival margin line, as landmarks for determining the
position of alveolar bone and teeth.
Extensive loss of alveolar bone and deformation of
the alveolar wall during a long edentulous period,
indicate that more specific instructions are needed to
support what can be difficult prosthetic treatments.
0 2001 Blackwell Science Ltd 267
268 L. V . J . LASSI LA et al .
Subjects and methods
A total of 355 post-menopausal women, age 48-
56 years (average 53.3), were included in this study. Of
these subjects, 230 had lost all the natural teeth in the
maxilla an average of 29.9 ( f 7.4) years ago and 125
still had natural teeth left, generally 8-10 teeth in
maxilla, not counting the wisdom teeth. It was possible
to determine the position of the incisors in 117 pa-
tients, canines in 110, premolars in 88 and molars in
93. All of these women were participating in a 5-year
study on osteoporosis and its risk factors and preven-
tion at the University of Kuopio (Klemetti, Lassila &
Lassila, 1996).
According to the clinical examination of the subjects,
the atrophy of the alveolar wall was often strong and
the dentures were generally old and quite poor fitting.
An impression of the mouth was taken and several
measurements made on plaster cast models of the
maxilla. To compare the position of the teeth in dentu-
lous and edentulous maxilla some basic planes, lines
and points have to be determined (Table 1, Figs 1 &
2a). All tracings and measurements were made manu-
ally with a screw measure, calibrated 125 x 0.02 mm
by one author and these were checked by another.
The median line runs sagittally from the labial plane
(LP), the transvere plane passing through the middle of
the labial edge of the incisive papilla to the posterior
border of the palate at the front of the foveolas, (fove-
ola plane, FP). This distance is the length of palate. To
determine the sagittal position of canine teeth the
distance from the incisive plane (IP) to the transverse
plane, passing through the middle points of the canine
teeth (CP), was measured. This was compared with the
distance from the incisive plane (IP) to the transversal
plane passing through the oral edge of the incisive
papilla, (oral plane, OP). The result gives the relation of
the sagittal position of the canine teeth to the plane
through the oral edge of the incisive papilla (OP).
The distances from the plane passing through the
labial edge of incisive papilla (LP) to the transverse
planes passing through the middle points of the first
premolars, (premolar plane, PP) and to the first molars,
(molar plane, MP) were measured and compared with
the length of one-third and two-thirds of the palate.
These results can help us to find the planes in same
reference regions of the edentulous maxilla and sagittal
positions of premolar and molar teeth.
Bilateral distances between the lingual gingival mar-
gins of canines (1 3T-23T), first premolars (14T-24T)
and first molars (16T-26T) (T, teeth) were measured
and compared with the bilateral distances between the
scar-lines (S) on the edentulous alveolar wall in the
same regions (13S-23S, 14S-24S, 16S-26S).These re-
lations are important to know in order to determine
the transverse position of the reference teeth. The
scar-line is a fine cord-like elevation or track on the
alveolar mucosa after healing of the tooth extraction.
This remaining line was easy to find in premolar and
molar area. In the canine teeth-area the scar line runs
usually on the buccal edge of alveolar wall and was
sometimes difficult to locate. In the incisor area the
landmark was generally broad because of the extensive
Table 1. Edentulous and dentulous maxilla. Marking of planes,
points and distances
IP
LP
OP
FP
CP
PP
MP
1 3T-23T
14T-24T
16T-26T
13s-23s
14s-24s
16s-26s
13f-23f
14f-24f
16f-26f
13a-23a
14a-24a
16a-26a
Transverse plane passing through the facial surface of
Transverse plane passing through the labial edge of
Transverse plane passing through the oral edge of
Transverse plane passing through the posterior border
Transverse plane passing through the middle points
Transverse plane passing through the middle points
Transverse plane passing through the middle points
Bilateral distance between the lingual gingival margin
Bilateral distance between the lingual gingival margin
Bilateral distance between the lingual gingival margin
Bilateral distance between the scar line on alveolar
Bilateral distance between the scar line on alveolar
Bilateral distance between the scar line on alveolar
Bilateral distance between the facial surfaces of
Bilateral distance between the facial surfaces of first
Bilateral distance between the facial surfaces of first
Total breadth of the edentulous alveolar wall in
Total breadth of the edentulous alveolar wall in
Total breadth of the edentulous alveolar wall in
central incisisors
incisive papilla
incisive papilla
of palate
of canines
of first premolares
of first molares
of canines
of first premolares
of first molares
wall in canine region
wall in premolar region
wall in molar region
canines
premolares
molares
canine region
premolar region
molar region
0 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 267-272
POSI TI ON OF MAXI LLARY TEETH 269
IP
Table 2. Difference between the distances from IP to CP and to
the plane through the oral edge of incisive papilla (OP) in
dentulous maxilla
Fig. 1. Diagrammatic representation of maxilla with profile of
the scar line (unbroken line, S) and the lingual gingival margin
line (broken line, T) and incisive papilla to the natural teeth are
shown. Other reference planes and lines: IP, incisive plane; LP,
labial plane of papilla; OP, oral plane of papilla; CP, caninus
plane; PP, first premolar plane; MP, first molar plane; FP, foveola
plane; a, alveolar line; and f, facial surface line.
loss of buccal alveolar bone and so the position of the
incisors was determined by the distance of the oral
edge of the incisive papilla.
The total breadth of the facial surfaces and the eden-
tulous and dentulous alveolar walls in reference re-
gions was measured.
For comparisons of the means analysis of variance
( ANOVA) was used.
Distances (mm) Mean s.d. n
IP-CP 11.82 1.30 110
IP-OP 12.08 1.18 110
Difference 0.26 P=NS
Results
Sagittal position of the canine teeth and central incisors
The difference between the distances from the plane
passing through the facial surface of the central incisors
(IP) to the plane passing through the canine teeth (CP)
and to the plane passing through the oral edge of
incisive papilla (OP) was on average 0.26 mm and
statistically non-significant (Table 2) .
The CP also passed very near by the oral edge of
incisive papilla and the sagittal position of canine teeth
in the edentulous maxilla can be defined well with this
landmark.
The position of the facial surface of the central in-
cisors can be determined also according to the oral
edge of the incisive papilla. The distance from the IP to
the OP was on average 12.0mm. This is about twice
the average length of the papilla in the edentulous
maxilla (Table 3 ) .
Sagittal position of the first premolar and the first molar
In dentulous maxilla, the distance from the LP, the
plane passing through the labial edge of incisive papilla
to the first PP, did not differ significantly (P >0.1) from
the length of one-third of the palate length, nor did the
0 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 267-272
270 L . V . J . LASSI LA et al .
Table 3. Correlation in length of incisive papilla between max-
illa with natural teeth and a edentulous maxilla
Lengths (mm) Mean s.d. n Lengths (mmj Mean s.d. n
Table 5. Difference in length of the palate (LP-FP) between a
maxilla with natural teeth and edentulous maxilla
Dentulous maxilla 7.74 1.55 120 LP-FP (dentulous) 44.90 3.34 89
Edentulous maxilla 6.27 I .42 228 LP-FP (edentulous) 43.27 3.75 228
Difference 1.49 P<O.OI Difference 1.63 P>O.O01
distance to the first molar plane (MP) from the length position of these teeth in the edentulous maxilla is also
of two-thirds of the palate length (Table 4). in the middle of the scar-line in the facio-lingual
The length of the palate from the labial edge of IP to direction.
the FP was on average 1.6 mm longer in dentulous In the presence of extensive loss of buccal alveolar
maxilla than in the edentulous maxilla (Table 5 ) . The bone the position of the scar line in canine region was
same difference can be seen in relation of the length of at the buccal edge or totally outside the alveolar wall.
incisive papilla in dentulous and edentulous maxillas Therefore, the canine teeth are situated so that three-
(Table 3 ) . The reason for this is the extensive loss in quarters of the facio-ligual breadth (about 6mm) is
the buccal alveolar wall and deformation of the labial outside the alveolar wall.
edge of papilla. The difference is clear but it will be The total breadth of alveolar wall in the edentulous
eliminated in the relative measurements of the practi- maxilla was about 2- 3 mm larger than that of the
cal technique for removable dentures. scar-line in premolar and molar region and showed
Thus, the sagittal position of the first premolar and that the atrophy of the wall was on average marked in
the first molar can be found in edentulous maxilla by these regions, but the variances were quite large. The
dividing the length of palate into three equal parts total breadth of the alveolar wall in the sulcus area in
where the PP is one-third and MP two-thirds back dentulous maxillas differed very little from the line of
from the LP. the facial surface of the teeth (1.0-2.0 mm). However,
it must be taken into consideration when moulding the
Transverse position of the reference teeth
The transverse position of canines, first premolars and
record blocks and bases of dentures for an edentulous
maxilla (Fig. 2b).
first molars on the CP, PP and MP were determined by
comparing the bilateral distances of lingual gingival
Discussion
margin lines beside the teeth and the bilateral distances
of the scar-lines in the same region in the edentulous
maxilla (Fig. 1). According to the measurements the
position of the scar-line in premolar and molar region
was buccal to the lingual gingival margin line. The
difference in the total breadth was 8.47 mm in premo-
lar region and 10.6 mm in the molar region, which did
not differ statistically from the facio-lingual breadth of
these teeth (Table 6). In practical application this is
about 5.0mm in the premolar region and about
6.0 mm in the molar region. The correct transverse
The alveolar bone loss in maxilla, especially in the area
of the canine and incisor teeth, as a result of long term
edentulousness and poor fitting dentures with insuffi-
cient opposing dentition, has been discussed previously
by Klemetti et al. (1996). The incisive papilla appears to
be a good landmark for the sagittal position of the
canine and anterior teeth, in spite of the deformation
of the labial edge confirming previous work (Watt &
Likeman, 1974; Likeman & Watt, 1974; Watt & Mc-
Gregor, 1986). The oral edge of incisve papilla was
generally unaltered in the edentate. When the mea-
Table 4. Length of the palate (LP-FP) in dentulous
maxilla and correlation between the distances from
the plane through the labial edge of incisive papilla to
the plane of first premolars (LP-PP) and first molars
the length of palate
Distances (mmj Mean s.d. 1/3, 213 x LP Difference
Lp-Fp
Lp-pp
44.90 3.34
14.47 2.35 1/3 X LP-FP= 14.96 0.49 P>O.1
(LP-MP) with the distance one-third and two-thirds of ~ p - ~ p 29.15 3.20 213 x LP-FP=29.93 0.78 PZ0.l
0 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 267-272
POSI TI ON OF MAXI LLARY T EET H 271
surements of the length of the palate in edentulous
maxilla were made from the labial edge of the papilla,
the standard deviation was quite great, but slight inac-
curacy in the total length of the palate does not have
particular effect on the practical treatment for remov-
able dentures.
Klemetti et al. ( 1996) and Klemetti et al. (1997) in
their study have divided the length of the palate into
three equal parts to determine the location of the
molar region in the edentulous maxilla. The present
results have cofirmed a method of locating the position
of the first premolars and the molars in the edentulous
maxilla.
The scar-line on the edentulous alveolar wall was
generally easy to see in the area of the premolar and
molar teeth and it was in the middle of original alve-
olar wall. The correct position for these teeth is in the
middle of this line in the facio-lingual direction. Ac-
cording to our study the position of the scar-line in the
edentulous maxilla differed from the lingual gingival
margin line, which was used as landmark line in the
previous studies by Watt 6 Likeman (1974) and Like-
man 6 Watt (1974). The reason for the divergence of
results could be based on the fact that our subjects
were edentulous for twice as long. The present study
gives the possibility to estimate more exactly the posi-
tion of teeth and also the breadth of the space buccally
outside of the alveolar wall, which has to replaced in
prosthetic treatment.
In severe atrophy of the anterior area of the alveolar
wall, the scar-line sometimes disappears totally and the
palatal rnucosa extends to the anterior side of the wall.
Therefore, the transversal position of the canines was
on the outer edge of the alveolar wall and the correct
position for the incisor teeth could be determined only
by the oral edge of the incisive papilla.
The results of these measurements may not always
be completely applicable in clinical use, e.g. because of
previous adaption of patients to incorrect dentures. In
these cases, however, it is possible to compromise.
These biometric quides can give considerable help in
the planning of prosthetic treatment, especially for
formulating record blocks and setting of artificial teeth
for patients, with a long edentulous history.
In conclusion, according to the result of the present
study in denture treatment of atrophic alveolar wall of
the edentulous maxilla, the correct position for the
different groups of teeth can be found with the follow-
ing criteria.
(1) The sagittal position of central incisors can be deter-
mined by the oral edge of incisive papilla, and the
distance i s about twice the length of the papilla.
( 2) The sagittal position of the canine teeth are also
related to the oral edge of IP and in transverse setting
an average of three-quarters of these teeth have to be
outside of the alveolar wall.
( 3 ) The sagittal position of the first premolar is one-
third and the first molar two-thirds the length of the
palate from the labial edge of incisive papilla. The
transverse position of premolar and molar is in the
middle of the scar line, and the distances of the facial
surfaces are about 5-6 mm buccal from this landmark
line.
Table 6. Differences between bilateral dis-
tances of lingual gingival margin lines of the
teeth (T) and the scar-lines (S) (edentulous
maxilla) i n same region and correlation with
facio-lingual breadth of teeth
Facio-lingual breadth of teeth
Distances (mm) Mean s.d. ?z Mean s.d. Difference
Canine teeth
13T-23T 24.25 1.92 115
13s-23s 26.32 3.54 227
Difference 2.07 8.05 0.68 5.98
First premolars
14T-24T 27.75 2.34 90
14s-24s 36.22 3.29 229
Difference 8.47 8.85 0.54 0.38 P = NS
First molars
16T-26T 34.28 3.21 107
16s-26s 44.89 2.92 229
Difference 10.61 10.77 1.13 0.16 P=NS
0 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 267-272
272 L . V . J . LAS S I LA e t a l .
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Fin-20520, Finland. E-mail: [email protected]
0 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 267-272