What I’m going to show you now is a series of slides of actual real life patients that have come in to our office to try to illustrate what these physical changes look like when you see them in real life. Here’s a patient who came in and has one single tooth missing. There’s a single tooth and on both sides what looks like is yellow up at the gum line is actually the root that’s become exposed. There’s been some bone loss around there, but if you look more closely in between the teeth, you can see how it’s concave. That’s because there’s been some vertical height of bone and it’s hard to illustrate or show you on a two-dimensional slide here, but if you can kind of imagine in between those teeth—you can try this on yourself if you have any missing teeth—you can actually feel the roots of the teeth and the ridge but where you’ve got missing teeth. Your finger just goes ‘boop’. It almost goes in and that’s what this person has, you can kind of see it a little bit on the two-dimensional screen.
Looking at the next slide, you’ll see I’ve drawn a line there approximately where the gum height would normally be if that tooth were not missing. It wouldn’t be straight across like that, but approximately in the middle part, there’s been a significant amount of bone loss there. Taking a look at this next picture showing two teeth that have been missing for well over ten years. Look at how wide the bone is around the molar and even around the tooth in the front—what we call the premolar. Look in between. In real life, the gum from one side to the other measures probably about three millimeters. Well, at least half of that is gum tissue and underneath that bone—that used to be at least ten millimeters wide, now,only about a millimeter and what’s the significance of it? Well if a person was looking at a denture, it probably wouldn’t be so important in this case. But certainly, if someone is considering an implant which has to have bone around it, it becomes significant. And in this next slide, I’ve drawn approximately where that bone width would be and how much bone would have been there when this person had their natural teeth.
Gaps in Teeth
Other things that occur, I talked about teeth shifting and here’s a person that came in and were wondering, “why am I getting gaps between my front teeth? I never had gaps. Take a look at my pictures of when I was younger, I had nice straight teeth but now I’ve got gaps.” A number of things are occurring here. Number one, there are no back teeth. We talked about how the back teeth normally stops the jaw from closing. When we lose those back teeth, we end up hitting on the front. The front teeth become the stops and they’re not designed to do that. They don’t hit edge to edge, they hit on an angle like this. So what tends to happen is we end up hitting these teeth like so and over the years, these teeth start to splay. They start to tip forward and spaces start to open up—so this is a result of not having back teeth. And the other thing that you can kind of visualize is that molar on the top right is slowly dropping down. You’re going to see this even more advanced in another slide in a few minutes, but this tooth is sliding down because there is nothing below it and if it continues, it will keep coming down until literally, it’s biting into the gums and or that tooth comes out of the bone.
Repercussions of No Back Teeth
Here’s a pretty severe situation showing what happens when we don’t have back teeth. We’re seeing a whole number of things here. We’re seeing bite collapse. The bite has closed up quite severely. We’re seeing the back teeth have over-erupted and have dropped down because there’s nothing below, and they are literally biting into the gums. We’re seeing the front teeth being pushed forward. They’re becoming very bucked once again because there are no back teeth. If you could see this person’s profile, you would see that their whole lower face is all scrunched up.
Importance of Timeliness
Another situation showing just a single tooth and what can happen in as little as six months. This person came in to see me because she wanted to have an implant placed for this missing tooth. What you’re seeing there is a false tooth on a little denture and this tooth had been removed approximately six months earlier. She’s had advanced bone loss and gum tissue shrinkage in that short period of time. Now normally it wouldn’t be quite so severe but in this case, she already had bone loss due to past infection, tooth infection, abscesses and gum problems in that area. So when the tooth was taken out, there were no steps taken to try to preserve that, and that’s why so much bone loss had occurred in such a short period of time. The difficult thing is she also wants a tooth that’s going to look very natural. She has a high smile, she shows a lot of teeth and a lot of gum tissue, and she wants these teeth to look as natural as possible and it’s going to be a challenge now to try and recreate what has been lost. It would have been much easier if we could have dealt with it at the time that the tooth was taken out. And of course, this last slide shows you, approximately, where that gum height would have been. It should be pretty much identical to its contralateral tooth on the other side, what you see there on the right side of your screen.
Combination of Issues
This is showing another gentleman also wondering why is his front teeth becoming loose and why are these teeth being pushed forward. This is a combination of a couple things. A combination of some gum disease which— involves bone loss, makes the teeth looser, but also he has lost back teeth so he’s getting bite collapse. His bite is closing up and these front teeth are being pushed forward. In our dental practice, of course we take x-rays for various treatments. This is a type of x-ray that is called panrax or panoramic. It goes all the way around the jaw, shows both upper and lower and here, what you’re seeing is the hard tissue, the bone. You’re seeing pretty much what you see here in these models. In the front, this person has her natural teeth still but in the back they’ve been missing teeth—top and bottom for many years. And if you take a look here is the bone level, and it’s quite high where the natural teeth are still there stimulating the bone. But if you take a look in the back, you can see it literally drops right down and the same thing happens on the top. In this next slide you’ll see I’ve drawn a line approximately where that bone height used to be and so this person has lost a lot of bone height and they’ve also lost width but you just can’t see it two dimensionally here. In the next slide, you’ll also see what happens in the upper.
Bone Loss and Our Sinus
Now in the upper, we lose bone in two different ways. In the lower, we just tend to lose it from atrophy, from the ridge shrinking in height. In the upper the same thing happens, we get atrophy of the ridge and so the ridge shrinks in this direction but up top here we also have a big empty space which is called the sinus. Anybody who’s ever had a sinus cold knows exactly where that structure is. Normally it, starts off very small when we’re kids. Once all our teeth have erupted, that sinus starts to enlarge and continues to get bigger and bigger and literally will stop when it senses the roots of the teeth and will stay that size. But if the tooth is removed or several teeth removed, that sinus will start to enlarge even more and in the case that we’ve lost all our back teeth, that sinus will enlarge and drop right down and we get bone loss from the ridge going this way. We get bone loss from the sinus dropping down and that bone that used to be 10-15 millimeters in height sometimes literally can be paper-thin. You could literally see through it, it looks like rice paper in the extreme case. And all this bone loss has implications if someone is considering either denture, because now they don’t have a ridge that’s going to hold a denture in place and of course has implications if somebody is considering implants because implants go where the roots used to be. They need bone around it and if we’ve lost the bone then we either can’t do implants or what we typically do is we can recreate or do some bone grafts to recreate that lost bone.
Unintentional Positive Side-effects
The other issue that sometimes people have with this bone loss particularly on the upper is there’s a drain for the sinus which is kind of typically in about the middle of the sinus and the floor of the sinus is about say here. What happens though is as this sinus starts to enlarge, that starts to drop down and the drain stays in the same place and it’s kind of like having the bath tub and not having the drain near the bottom where it needs to be but way up high. Well you can imagine there’s a lot of fluid and water that can collect and just can’t drain out. Hence, people who have been missing teeth for a long time who have these enlarged sinuses tend to have a lot of sinusitis and sinus infections. So sometimes when we go and do these grafts to restore the bone that’s been lost one thing that they come back and say, “Gosh, my sinuses are a lot clearer than they used to be.” It’s not our goal but it’s almost like a good side effect of what we’re doing. We’re basically taking the mouth and restoring it back to its normal health, contour, and physiology.