1) INTRODUCTION The alveolar process is the bone that forms and supports the tooth sockets (alveoli).

The process of residual ridge resorption starts soon after the dental extraction / lost following the extraction of teeth. The bony socket and adjacent soft tissues undergo a series of tissue repair reactions including acute inflammation, rapid restoration of epithelial integration, and connective tissue remodeling. Histologic evidence of active bone formation in the bottom of the socket and bone resorption at the edge of the socket are seen as early as 2 weeks after the tooth extraction, and the socket is progressively filled with newly formed bone in about 6 months. Rapid bone remodelling subsides by this time but continuous bone resorption may persist at the external surface of the crestal area of the residual alveolar bone, resulting in considerable morphologic changes of bone and overlying soft tissues over the years. This phenomenon has been described as the REDUCTION OF RESIDUAL RIDGES or RESIDUAL RIDGE RESORPTION (RRR). The alveolar process consists of the:
a)

Inner socket wall of thin, compact bone called the Alveolar bone proper (Cribriform plate).

b)

Supporting alveolar bone, which consists of cancellous trabeculae, and the facial and lingual plates of compact bone. The interdental septum consists of cancellous supporting bone enclosed within a compact border. All parts are interrelated in the support of the tooth. Occlusal forces that

are transmitted from the periodontal ligament to the inner wall of the alveolus are supported by the cancellous trabeculae, which in turn are buttressed by the labial and lingual cortical plates.

Continuous remodeling of the socket occurs by the action of osteoclast and the osteoblast. Bone is resorbed in areas of pressure and formed in areas of tension. Vascular supply Blood vessels from superior and inferior alveolar artery. Dental arteriols through PL enter the perforation in the cribriform plate. Small vessels emanating from the facial and lingual compact bone also enter the marrow and spongy bone.

The cellular activity that affects the height, contour and density of alveolar bone is manifested by three areas: i) Adjacent to the PL, ii) In relation to the periosteum of the facial and lingual plates and iii) along the endosteal surface of the marrow spaces. 2) TOOTH EXTRACTION, WOUND HEALING AND FORMATION OF THE RESIDUAL RIDGE Remodelling of residual ridge occurs as the consequences to healing of a significant bony and mucosal wound created by tooth extraction. Trabecular bone formation starts from apex to crest of the socket whereas the osteoclastic bone resorption takes place on the surface of the residual ridge, a combination of which results in a distinct porosity on the crest of the residual ridge alveolar bone. Coarse, birefingement collagen fibres formed a preliminary framework along which the trabecular and were fabricated by fibroblasts, marrow reticular cells and osteoblasts. Trabeculae were absent where this preliminary collagenous framework is failed to form. Subsequent remodeling of the small primary trabeculae produced secondary trabeculae that resembled the original cancellous 2

bone pattern. The delayed tooth socket healing often observed in poorly controlled diabetes inevitably causes a poor alveolar ridge contour. A dense network of collage fibers normal fills the socket soon after tooth extractions and the defect in diabetes mellitus may be due to a reduced collagen production and an absence of these fibers. Precursor template collagen for bone wound healing: The collagenous extraction socket matrix forms before bone formation, and it has been hypothesized that this matrix serves as a template or framework that orientates the forming bone trabeculae. Controversy surrounds the nature of the collagen molecules that provide this template function. However, because of its potentials in guiding bone, wound healing, the major emphasis of current biologic studies of residual ridge remodelling is directed toward the characterization of this template stage of bone remodelling. A two stage process of bone formation is evident in endochondral ossification, in which cartilage tissue is initially present. Chondrocytes undergo sequential histo-differentiation, which result in cellular hypertrophy and apoptasis. The remnant hypertrophic cartilage matrix is believed to provide the template scaffold for osteoblasts to precipitate bone extracellular matrix. The template cartilage matrix is eventually resorbed endochondral synchondrosis of the skull base, and mandibular condyle. One of the most obvious feature of the healing of tooth extraction sockets is the absence of precursor cartilaginous tissue. This unique feature has been described by a general hypothesis that the tissue regeneration is considered to be a reiterated process of tissue embryogenesis. In embryos, maxillofacial bone including tooth bearing alveolar process, is formed through intramembranous bone formation, which is different from endochondral ossification. In intramembraneous bone formation examined in calvaria, the intramembranous bone formation, which is different from endochondral ossification. In intramembranous bone formation examined 3 in calvaria, the initial

ectomesenchymal cells directly differentiate into osteoblasts, by passing the deposition and resorption of hypertrophic cartilage matrix; osteoblasts can directly deposit osteoid tissue, which is then calcified. It is of particular interest that recent investigations reported the transient expression of cartilagenous precollagen type II mRNA during intramembraneous bone formation type II collagen is a major collagen type of hyaline cartilage and thus has been long considered to contribute to the structural integrity of cartilage tissues and provide a template during endochondral ossification. The involvement of type II procollagen mRNA in different tissues other than cartilage may suggest some as yet undefined function of type II collagen unrelated to chondrogenesis. In recent years, type II collagen has been further investigated and its two alternative splicing variants of type IIA and type IIB are found to have differing cell origins. Type IIA is found in noncartilaginous tissues, whereas type IIB has a strong association with chondrocytes and cartilage tissue formation. The expression of type II procollagen mRNA has been identified in the healing extraction sockets in experimental animals by the method of RNA transfer blot analysis and is situ hyridization. Analysis of studies on the uncomplicated healing of extraction wounds have shown that after the clot formation, granulation tissue is gradually replaced by connective tissues and later by intramembranous bone, without cartilage formation. A cluster of cells that are associated with the early socket wound healing have been shown to express type II collagen mRNA. A puzzling finding is that investigators have failed to detect the presence of protein collagen type II by way of immunohistochemical studies in actively healing extraction sockets. This may be suggestive of either lack of collagen type II translation or difficulties in detecting this protein in the healing socket. Some of the questions that need to be answered in the extraction socket of what are the role of these 4

cells in the socket healing if type II collagen protein is synthesized. Do systemic or local factors influence the gene expression pattern during socket healing. Two-stage process of bone formation: Cartilage collagen fibrils are composed of a group of different type of collagen including type II. The surface of this fibril is associated with small collagen type IX. Because of the exposed perifibril location and the interactive peptide structure of type IX collagen, it has been postulated that type IX collagen plays a molecular bridging role in the extracellular matrix and contributes to formation of a cartilage tissue architecture. It has been reported that collagen type IX mRNA is also expressed in early hiealing stage of extraction sockets

Further analysis of residual ridge remodeling in rats have revealed that the 1 (IX) collagen mRNA, which was expressed in the extraction socket, was different and markedly shorter than that of cartilage. The short form of type IX collagen omits the multiple exons, that encode the Amino terminal globular domain (in above figure). Therefore this alternation expression of the short form of type IX collagen, which lacks the interactive peptide structure, may explain why cartilage tissue is not assumed in the extraction socket. However, the function of the short form of type Ix collagen in residual ridge remodeling remains to be classified. Recent immunohistochemical data suggest that type IX collagen is present only in the early bone formation stages of extraction socket healing and seems to disappear during the maturation stages. It has been characterized in the 5

similar transient expression of the short form of type IX collagen along with type II collagen is embryonic chicken cornea, in which the principle orthogonal fiber architecture of the mature cornea is organized according to the template tissue, primary cornea stroma. Both cornea and bone posses the similar orthogonal pattern of collagen fibrils. The detailed molecular assembly of type II and the short form of type IX collagen in bone remodelling is not elucidated. However, it is tempting to speculate that the transient matrix containing short type IX collagen may be involved in a tissue guiding role in alveolar bone repair, as used in avian eye formation. Transgenic and inactive gene allelic manipulation in experimental animals: To understand the role of a specific molecule, one can generate animals harboring an experimentally introduced mutation to the molecule or inactivate the corresponding gene. Such transgenic animals can provide a powerful tool to investigate the consequences to the missing biologic role of a specific molecule. Several transgenic mice have been generated with defective type II collagen. The introduced mutated pro 1 (II) collagen chains appears to be included in a procollagen molecule and prevent folding into a stable triple helix. Transgenic mice with functionally impaired Type II collagen result in chondrodysplasia into dwarfism, short and thick limbs, a short snout, a cranial bulge, a cleft palate, delayed mineralization of bone, and a severe retardation of growth for practically all bones. Because type II collage comprises the major constituent of cartilage, the principal consequence of this mutation is anticipated to cause disorganization of the growth plate. However, it is interesting to note that both endochondral bones and intramembranous bones are affected by the Type II collagen mutation. Nakata reported the generation of transgenic mice harboring the minigene of 1 (IX) collagen with an inframe delation of the central domain. Some homozygons transgenic mice displayed mild proportionate dwarfism. The vertebral bodies were ovoid in shape as a result of a mild ossification defect, and the end plate in the mid-dorsal region were irregular, otherwise, the offspring of 6

the transgenic mice sunlived to their maturity. After reaching maturity, onset of osteoarthritic changes become apparent particularly in the anterior part of the weight bearing areas of the tibia. They reported that even before the histologic onset of osteoarthritis, a significant decrease in the intrinsic compressive stiffness was found in the articular cartilage of the transgenic mice. Furthermore, corneas of the transgenic offspring appeared opaque or irregular and were sometimes infiltrated by capillary vessels. The opthalmopathy was found in about 15% of transgenic animals. These results strongly indicate that type IX collagen may play diverse biologic roles in various tissues, including localized bone remodelling. Recently, 1 (IX) collagen knock-out transgenic mice were developed. The neogene was inserted in the exon 8 of the 1 (IX) gene by homologue recombinations, which resulted in the total inactivation of 1 (IX) alleles, including both premolars. Therefore, this animal model allows an investigation of the functional role of type IX collagen as a potent element for alveolar bone regeneration. Wild type and homologous mutant mice were analyzed to elucidate the role of type IX collagen in residual ridge remodelling. To evaluate alveolar bone repair, the specimens were obtained at 7 days and 14 days after tooth extraction. The extraction socket of mice with inactivated 1 (IX) alleles indicated that there was a considerable retardation in the formation of the trabecular bone pattern as compared with the healing socket of the control genotypically normal mice. The results indicated that the trabecular bone pattern was often disturbed in knock-out mice with some formation of cortical bone within the socket. These data suggest that there may be two distinct bone remodelling prcoesses. In the trabecular bone remodelling. The presence of type II and IX collagen precursors seems to be necessary. In the cortical bone remodelling, type II and IX collagen precursors may not be prerequisite. Successful socket healing

may use the former process, which require the transient expression of template collagens, including type II and IX. 3) BONE REMODELLING PROCESS Modelling is the correct word for the microscopic changes in the bone morphology. Ridge resorption is a misnomer because, resorption is a part of a process that leads to edentulous bone loss, where atrophy implies a passive process. Therefore, the term remodelling is used to describe the physiological process of bone loss. Since in our topic were are including even the pathologic process of the bone loss, thus it would be apt to consider it as residual ridge resorption. Remodelling of bone involves three stages. This was put forth by Frost and that has been elaborated on by several investigators since, several stage of cellular activity can be distinguished: 1. Activation phase. 2. Resorption phase. 3. Formation phase. Activation : This is the first stage of remodeling persons which begins as a result of specific local or systemic stimuli. It occurs at the microscopic level on the surface of the lamellar bone. Whether it could be cortical or trabecular. Activation stimulation the rest of the resorption process. It shows the migration of osteoclast precursors to an area of the bone surface to be resorbed, attachment of these precursor cells, and subsequent fusion of these cells into multinuclear osteoclasts. Resorption : The resorption begins, as the osteoclasts adhere to the bone surface in response to the stimuli. These osteoclasts are probably derived from the special circulating monocytes. Resorption may occur in the depth of the haversian system of the compact bone or outside surface of the trabecular bone. 8

Often this resorption occurs parallel to the stress placed to bone and it influences the formation process. This process is followed by the deposition and organic matrix which is responsible for stress resistance of bone after calcification had occurred. Resorption also occurs in the absence of stress, but it does so in a less organized manner. This specific factor responsible for resorption is yet to be determined. But, there is 8-10 days delay period. The resorbed surface is morphologically identified as cement line. Formation phase : It is signalled by the local mesenchymal cells into osteoclasts which concentrate, or aggregate on the same surface and begin to lay down the organic matrix. There are skeletal envelops: i) Periosteum, ii) Haversian system, iii) Endosteum and iv) Trabecular system Each of the skeletal envelops have characteristic bone balance which is generally not zero. During this stage osteoblasts differentiate at the sites previously resorbed and start to deposit osteoid and bone on completion of the phase, the site enters a resting phase, with no discernibe osteoid remaining between the lining cells and the mineralized bone. Thus a close anatomic and functional relationship exists between resorptive and formative cells at discrete remodelling sites, referred to as Basic Multicellular Unit (BMU) of bone remodelling. This is, in all likelihood, responsible for the phenomenon that many treatment of metabolic bone disease developed to inhibit resorption result in simultaneous inhibition of formation. Numerous examples of this phenomenon exist, and various schemes have been devised to selectively affect then the resorptive phase or the formative phase of the remodelling cycle. The rate of bone remodelling is determined by the number of BMU operative at any given time. For the normal human skeleton, activation occurs about once every 10 seconds and the total number of 9

BMU in operation at any time has been estimated to be 35 million remodelling is conceivably initiated at a particular site either by mechanical triggers conveying some type of message to cells initiating formation or resorption or by unknown sensory mechanisms that indicate to the cells. The need to initiate a remodelling sequence that bone in a certain area has to be replaced. 4) HISTOLOGICAL RESORBTION OBSERVATION OF RESIDUAL RIGE

The mandible and maxillary ridges differ in gross appearance from other surface of the same bone. Generally, the bone surface is smooth and undulating and contains minute opening into the nutrient canals. Foramina are larger opening through which vessels and / or nerves of greater diameter pass. Most foramina are well known anatomic entities. Neither the foramina nor the minute openings resemble the irregular defects present in the residual alveolar ridge. The gross appearance of the defects ersembles cancellous bone. The histologic sections confirmed the observation. Histologically a well defined cortex with a lamelled surface was not in evidence. Lamellated surface had been resorbed, and the Haversian systems were undergoing resorption. Resorption was a constant factor. An sections with defects showed periosteal resorption. There was no evidence of repair. There were no reversal lines in the sections. The resorption penetrated the bone marrow spaces. The submucosa and periosteum invaded the bone marrow space replacing the marrow with dense C.T. It was observed histologically, the mandibular ridge resorbs more readily than the maxillary ridge. However, the mandibular ridges contained more supporting bone than did the maxillary ridges. Obviously, the supporting bone offered no resistance to the resorption. 10

The resorption continued to expose the cancellous bone to the periosteum Campbell reported that denture wearing patients experienced more resorption of the alveolar process them did non denture wearing subjects.

A study was conducted in 1984: To find out the histologic feature of

edentulous ridge. The objective of the study was to observe the nature of the edentulous ridge of subjects who were edentulous for varying time periods. Some of the subjects had worn denture while others had not. Connective tissue was studied in the ridge crest, buccal and lingual region. The feature observed were: 1. Thickness, 2. Density, 3. Presence of inflammatory cells, 4. Presence of an osteogenic periosteum. Observations: 1. The thickness of C.T. was found to be decreased from the normal in the ridge crest region in both non denture and denture wearing groups. In other regions (lingual and buccal) the thickness was considered normal and no difference was noted between groups except for increased thickness in the lingual region of the non dentuer wearing groups. 2. The density of connective tissue was increased in non-denture wearers. But evenly divided between normal and increased in denture wearers. 3. Inflammation in C.T. was slightly greater in denture wearers group. But was not a prominent findings. 4. When any type of periosteum was present it was generally fibrous in nature. Hence, we conclude that probable during healing process after extraction of teeth, the thickness of ridge C.T. is decreased while the density is increased unrelated to the wearing of denture. 11

In brief, the microscopic studies / histological revealed the following: 1. Varying degrees of keratinization, acanthrosis, thickness, edema and architectural pattern of epithelium in the same month and between subjects. 2. Varying degrees of inflammatory cells from clinically normal to frankly inflammed areas in both denture and nondentuer wearing patients. 3. Lymphocytes, plasma cells, mast cells and osteoclasts. 4. Dense, fibrous connective tissue (sometimes hyalinized) frequently observed over crestal bone with fibers running parallel to epithelial surface. 5. A vascular plexus outside the periosteum in areas of bone apposition. 6. Small blood vessels in close contact with the bone margin in areas of bone resorption, sometimes, in the lacunae with positive correlation between the degree of inflammation, vascular reactions and bone resorption. 7. Marked diapharase activity in areas of bone remodelling either formation or resorption. 8. AT phase activity in areas of bone formation and acid phosphatase activity in areas of bone resorption. 9. The lack of evidence of bone resorption in areas which do not have inflammatory cells. 10. Endosteal bone deposition reinforcing internal structure where external surface has been affected by resorption. 11. Lack of periosteal lamellar bone on the external surface of the crest of the ridge. 12. A roughened crestal bone surface which is either actually resorbing or is inactive, but without versal lines on the external surface of the crestal bone. 12

13. Development of secondary Haversian systems in remodelled compacted endosteal bone. 14. Microradiographic evidence of mandibular osteoporosis including increased variation in the density of osteons, increased number of incompletely closed osteons, increased endosteal porosity and increased number of plugged osteons. 5) FACTORS AFFECTING RESIDUAL RIDGE RESORPTION As there is wide difference in the individual regarding the rate of the residual ridge resorption. Some patients show marked change where as others minimal changes in the ridge form over a period of time. According to the literature rate of bone loss is generally greatest immediately following tooth extraction. Mandibular bone loss occurs at a more rapid rate when compared to that of maxillary. Epidemiologic studies are useful in trend finding investigations of multifactorial diseases. It is entirely possible that RRR is a multifactorial diseases and that the rate of RRR depends on one single factor but on the concurrence of two or more factors, which may be called cofactors. Many years ago, it was suggested that for convenience, possible factors could be divided with four major categories. This pattern of division was again revered in 1998 by Leili Jahamgeri with few additions. 1. Anatomic 2. Prosthodontic. 3. Metabolic. 4. Functional. 5. Others. 1. Anatomic : 13

This includes : a) Size, b) Shape, c) Form, d) Space between ridges, e) Muscle attachments, f) Action of tongue. It is postulated that RRR varies in the quality and quantity of the bone of the residual ridges. It can be said that RRR anatomic factors. It is the amount of bone which is regard to the time count of RRR. If denser of bone slower is the resorption. Although the broad high ridge may have a greater potential bone loss. The rate of vertical bone loss may actually be slower than that of a small ridge because there is more bone to be resorbed per unit of time and because the rate of resorption also depends on the density of the bone. Quality of bone : On theoretic grounds if everything is normal. The denser the bone, the slower the rate of resorption, merely because there is more bone to be resorbed per unit of time. In actuality everything is never normal. Every patient is different especially in regard to the metabolic factors. Wolfs law It postulates that all changes in function of bone are attended by definite alteration in its internal structure and forces within the physiological limits are beneficial in their massaging effect. On the other hand, increased or instained pressure through its disturbance from the circulatory system produces bone resorption. The amount and frequency of stress and its distribution and direction are important factors in treatment planning. 2. Prosthodontic factors Clinical observations indicate that excessive alveolar bone resorption can be caused by physiologically intolerable forces produced by functioning complete dentures.

14

The inherent denture factors which may affect the supporting structures include: i. ii. iii. iv. v. The occlusal forms of the teeth. The alignment of the denture teeth / occlusal pattern. Deformation of the denture bases. Materials with which denture teeth are made and The effects of the loss of proper occlusal vertical dimension (over closure). i) The occlusal forms : The form of the occlusal surfaces of artificial teeth, weather of the Anatomic, Non anatomic or 0 degree configuration, must have some effect on chewing efficiency and on prices tending to distort the dentuer bases.
-

One of the earliest opponents of the anatomic tooth form was French who coined the term cusp trauma as one of the most serious defects that had to be guarded against in complete denture construction. Soon after, Sears developed his non anatomic tooth form which initiated the introduction of many new designs to denture teeth throughout the years.

Although disagreements continues to the advantages of one tooth form over another. The subject has been removed from the theoretical to a more scientific level.

ii)

Chewing efficiency : Results of early studies on chewing efficiency with various occlusal forms were contradictory. Thompson and Trapozzon and Lazzari found anatomic teeth to be more efficient than non anatomic teeth, whereas Soboik and Manly and Vinton found no statistical difference between the efficiency of the anatomic and non-anatomic teeth. 15

More recent studies have shown that there is no statistical difference in the chewing performance in denture teeth with cuspal ranging from 0 to 30 degree. Aside from studies of chewing efficiency using analysis of masticated test foods, the use of strain gauges attached to indication of denture teeth and electromyography has been applied to this problem Hickey and Asso demonstrated that there was less activity from the closing muscles when using anatomic (33 degree) teeth than when using 5cm Anatomic (20 degree) or non anatomic (0 degree) teeth in tests of chewing efficiency.
iii)

Occlusal pattern The arrangement of individual teeth in complete dentures includes a myraid of possibilities ranging from a flat occlusal plane with 0 degree teeth to a curved configuration which allows anatomic teeth to guide and pass over each other in close harmony with mandibular movements.

iv)

Denture base deformation Studies done by Askew and Hoyer showed that when the mandible with denture was pulled into lateral and protrusive more deformation was caused under the denture with anatomic tooth form than with non anatomic tooth form and same was with acrylic resin denture bases which resorbed the ridge more than the metal base when used with anatomic teeth than with non anatomic teeth.

v)

Tooth material the material from which the denture teeth are made may have some effect on the forces transmitted through the denture base material to the supporting ridges. It is said that porcelain tooth when placed causes more resorbtion of ridge

than acrylic tooth.

vi)

Loss of occlusal vertical dimension (over closure) The loss of proper occlusal vertical dimension after the insertion of complete dentures results 16

in the triggering of a cyclic series of event detrimental to the health of the residual alveolar ridges. Denture settling is one of the most common terms associated with complete denture prosthetics, yet it has been excluded from prosthetic glosseries and textbooks. This elusive term implies a sinking of the denture bases into the supporting structures. Moses described settling as a reorganization of the osseous and mucosal elements underneath the denture base. Many authors have observed that overclosure causes the mandible to be moved or rotated in an upward and forward direction causing occlusal disharmony and excessive trauma to the anterior region. Several authors have presented detailed procedures for adjusting the occlusion to allow for a forward shift of the mandible during over closure without occlusal interferences. The use of little or no vertical overlap in the anterior denture teeth has been advocated by authors interested in preventing trauma to the anterior areas of the mouth. 3. Metabolic Factor and System General body metabolism is the net sum of all the building up (anabolism) and the tearing down (catabolism) going in the body. In general terms, anabolism exceeds catabolism during growth and convalescence, levels off during most of adult life, and is exceeded by catabolism during disease and senoscence. Bone has its own specific metabolism and undergoes equivalent changes. At no time during life is none static, but rather it is constantly rebuilding, resorbing and remodelling subject to functional and metabolic stresses. The four main levels of bone activity are : 1) Equilibrium, 2) Growth, 3 ) Atrophy, resulting from decreased osteoblastic activity, as in osteoporosis and in disuse atrophy and 4) Resorption, caused by increased osteoclastic activity, as in hyperparathyroidism and in pressure resorption. Both sides of the equilibrium 17

must be known to understand bone metabolism. The relative activity of both the osteoblasts and the osteoclasts must be known. In equilibrium, the two antogonistic actions are in balance. In growth, although resorption is constantly taking place in the remodelling of the bones as they grow, increased osteoblastic activity more than makes up for the bone destruction. In osteoporosis, osteoblasts are hyperactive whereas in the resorption of hyperparathyroidism, increased osteoblastic activity is unable to keep up in the increased osteoclastic activity, the normal equilibrium may be upset and pathologic bone loss may occur. If either bone resorption is increased or bone formation is decreased, or if both occur. Since bone metabolism is dependent on cell metabolism, anything that influences cell metabolism and specifically, the metabolism of osteoblasts and osteoclasts is of cells in general and hence the activity of both the osteoblasts and the osteoclasts. Parathyroid of hormone influences the excretion of phosphorous in the kidney, and also directly influences osteoclasts, the degree of absorption of calcium, phosphate and proteins determines the amount of building blocks available for the growth and maintenance of bone. One of the most interesting metabolic phenomena concerns the antagonistic effects of the Antianabolic Hormones (the adrenal glucocorticid hormones including cortison and hydrocortisone). According to Reifenstein in the young person, there is a relative predominance of anabolic hormones resulting in continued growth and maturation of the skeleton, he further states, as people get older, especially women past the menopause, the anabolic hormones are so reduced that the antianabolic hormones are in relative excess, with the result that bone resorption may take place faster than bone formation and that bone mass may be reduced. Systemic Factors The influence of these factors can be explained on the statement given by Glickman. The status of bone equilibrium is variable, depending on the 18

physiologic and pathologic process of the entire body for its regulation, whereas the results of systems disturbance, the microscopic equilibrium is shifted in favour of bone resorption, a similar condition prevails in alveolar bone loss of alveolar bone occurs regardless of the condition of gingival tissue or the structural details of prosthetic appliance. Hormone : The three main principal hormones that regulate the plasma concentration of calcium are:
1.

1,25 dihydroxy cholicalciferol : This is a steroid hormone formed from vit. D by successive hydroxylation in the liver and the kidney. Its primary action is to increase the calcium absorption from the intestine and mobilize this ion from the bone and increase the absorption from the kidney by approximately 90%.

2.

Hypophosphatemia : Since low phosphorous concentration in the incubation medium of bone culture also has been found to enhance bone resorption; these effects of hypophosphatemia may represent a direct effect of serum phosphorous on bone to enhance bone resorption. Recently, however, it has been show that hypophosphatemia enhances the synthesis of 1.25 dihydroxycholicaliferol, which is the active metabolite of vit. D and which has been shown to stimulate bone resorption. Thus, it is possible that the increased resorption seen in person with hypophosphatema is in past of the result of excess, 1,25 dihydroxycholicalciferol. In any case it is clear that hypophosphatemia mediates directly, or indirectly a marked increase in bone resorption. Moreover, in experimental animals suggest that normal levels of serum phosphorous influence the basal level of bone resorption through further work is required to be certain of the point. In addition to these results in experimental animals, it was found be means of certain studies that hypophosphatemia in a human subject was associated with increased boner resorption. Since phosphorous 19 is ubiquitous in nature,

hypophosphatemia rarely, if ever occurs as a result of a deficiency of phosphorous intake. Hypophosphatemia may occur in patients with duodenal ulcers who are treated with antacids containing aluminium hydroxide gel, which binds phosphorous and renders it unabsorbable varying degree of hypophosphatemia are also seen in patients with impaired of renal tubular resorption of phosphorus, although we would expect hypophosphatamia of either glot or renal origin to result in increased resorption further clinical studies will be necessary to settle this issue. This can be included in bone loss due to increased resorption. Parathyroid Hormone Basic research is not definite in disclosing the exact mechanism by which the parathyroid hormone regulates the calcium-phosphorous balance in the blood. The chief argument at present is whether the hormone acts as a direct control on the apposition and resorption of bone or primarily on the kidneys by influencing calcium resorption by the tubules. When the parathyroid hormone is injected (hypoparathyroidism), there is an immediate rise in the renal excretion of phosphate. This disturbs the blood ca-phosphorous ratio by raising the blood serum calcium level. Then, phosphates are called from the bone bank by osteoclastic activity. The parathyroid hormone has another function of maintaining the blood level of the calcium ion, the calcification of bone tissue will be retarded to pressure the blood level of the calcium ion. This is related to the action of vit. D in an antagonistic manner. Parathormone maintains blood calcium by mobilizing it from the bones by osteoclastic activity. Vit. D maintains blood calcium by increasing the absorption of calcium from dietary source in the intestinal tract. One of the most important systemic factors influencing the rate of osteoclastic bone resorption is parathyroid hormone (PTH). Under normal conditions, PTH secretion is controlled by serum calcium concentrations through a negative feedback mechanism. A slight decrease in serum calcium 20

concentrations, as for example during the night when little calcium is being obsorbed from the gut, stimulates the parathyroid glands to secrete PTH, which in turn stimulates bone resorption, then by delivery more calcium to the extracellular fluid and closing the feedback loop. The cause of high PTH secretion can be divided into two categories: 1. Primary hyper parathyroidism. 2. Secondary hypoparathyroidism. Which occurs in a number of different clinical settings. High PTH stimulates bone resorption and there by causes bone loss. In primary hyper parathyroidism, the function of the parathyroid glands is abnormal, in that an abnormally large amount of hormone is secreted and as a result, bone resorption is increased. In secondary hyperparathyroidism, there is no abnormality in the parathyroid glands, the excess PTH secretion is secondary to a fall in serum calcium concentration and represents an attempt to return the serum calcium to normal. A fall in serum calcium may be due : 1) Too little Ca being absorbed from the gut, 2) Too much calcium being excreted in the urine, and 3) Calcium being lost from extracellular fluid to fetus during the third trimester of pregnancy. In all of these causes of secondary hyperparathyroidism. The parathyroids attempt to maintain serum calcium at the expense of bone calcium. Decreased external calcium absorption may result from 1) Inadequate calcium intake, 2) small bowel disease, such as sprue, in which there is impairment of the absorptive process, 3) liver disease which may impair fat absorption and thereby promote formation of insoluble calcium soaps, 4) Partial gastrectomy which decreases calcium absorption as a result of poor mixing of small bovel contents

21

and by other mechanism and 5) A deficiency of vit. D, which may result from poor fat absorption. Estrogen and Rogen Deficiencies In general, the sex hormones (Androgenes and estrogens) promote a protein anabolic action on all tissues including bone. A striking storage of nitrogen and calcium occurred in individuals with postmenopausal of serile osteoporosis in one study when these hormones one administered. More than half of the women over 50 years of age showed Roentgenographic, evidence of diminishing bone mass in a study by Albright and Reinfestein. Postmenopausal osteoporosis is the most common form of this condition, the aging person produces less and less of the Androgens and ostrogens, which results in faulty protein metabolism for tissue repair. In estrogen deficiency, the bone loss is not uniform, the amount of cortical bone does not decrease significantly, whereas the amount of cancellous bone in the metaphysis of the long bone decrease dramatically, the information available, to date thus suggests that, with regard to bone resorption, estrogen deficiency in vivo increase osteoclast numbers. Parallel with an increase in BMUs. The increase in osteoclast numbers occurs primarily on endosteal cancellous bone surface, and estrogen treatment reverses this effect. Estrogen treatment of estrogen-deficient post-menopausal women does not change the average depth of the osteoclastic resorption lacunae which suggests that the resorptive activity of individual osteoclasts is not affected by estrogen. Osteoporosis & RRR Osteoporosis is due to insufficient formation of the organic matrix. This condition is fundamentally a disturbance of protein metabolism and involves vitamins, hormone, and nutritional factors. This condition is usually found in edentulous patient. The clinical and pathophysiologic viscos of osteoporosis has 22

been refined recently to the concept of type I and type II osteoporosis. Type I osteoporosis is defined as the specific consequence of menopausal estrogen deprivation, and characteristically presents the bone mass loss, notably in the trabecular bone. Type II osteoporosis reflects a composite of age related changes in intestinal, renal and hormonal function. Both cortical and trabecular bone are affected in type II osteoporosis. In either case, one of clinical manifestations of osteoporosis is observed as less radiographic bone density. The maxillary residual ridge was reported to be significantly smaller in postmenopausal osteoporotic women while their edentulous mandible remained the same as the age-matched controls. A knife edged ridge is formed when bone resorption occurs at the labial and lingual surface of the residual ridge in preference to the occlusal surface. Postmenopausal women with lower bone densitometeric scores exhibited a tendency to develop a knife edge ridge in the mandible. Islands of langerhans The failure of these glands to produce sufficient insulin for the proper utilization of glucose causes diabetes mellitus, the high blood sugar with the spillover into the urine is well known. The syndrome of poor healing, low tissue tolerance, and rapid resorption of bone associated with the diabetic patient is recognized, but the intrinsic causative factors are not. The explanation for this syndrome is that, in the absence of insulin, a relative nitrogen starvation amina acids being divested from protein synthesis. A diabetic controlled by either insulin or diet is not affected by this mechanism. However, perfect control is rarely possible. Therefore, a word of caution and explanation to diabetic patients is necessary so that they can appreciate their prosthetic difficulties. Minor affect of other hormones Thyroid hormones : The thyroid glands are responsible for the regulation of the rate of metabolism. Hyperthyroidism increases the metabolic rate so that a negative nitrogen balance results. Such a balance is equivalent to protein deficiency, which can be a direct cause of osteoporosis. Thyroxine also has a 23

direct influence on the kidneys, causing an increased excretion of Ca and phosphorous. This depletion of Ca and phosphorous results in decreased bone apposition and increased osteoclastic activity to marshal these elements from the bone to compensate for their depletion. Growth hormone : Increases calcium excretion in urine, but also increases the absorption from the intestine. This effect may be greater than the effect of excretion with positive calcium balance. Sex : Women have less bone mass when compared to men. Age : As the age advances there is decreased bone formation and increased resorption. Suprarenal glands : The adrenal cortex produces steroid hormones called corticoids. One of these, cortison, retards osteogenesis. It was shown experimentally that administration of ACTII interfered with the healing of bone in rachitic rats whose treatment consisted of administration of Ca and Vit. D cortisone and related steroids are antianabolic, may induce the formation of glucose from noncarbohydrates, and may increase the calcium loss by direct affect on calcium excretion. The prolonged use and administration of such steroids are considered very dangerous to bone tissue. Functional : when force within certain physiologic limits is applied to living bone, that force, whether compressive, tensile, or shearing brings about by some unknown mechanism the remodeling of the bone through a combination of bone resorption and bone formation, the functional factors of frequency, intensity, duration and direction of force are somehow translated into biologic cell activity. In as much as the end result is brought about by cell activity, the metabolic factors are important. However, in that cell activity is influenced by force, the functional factors are also important. Evans stresses that mechanical factors constitute just one of several types of factors that operate in the development and maintenance of the normal for and size of bone. Henneman and Wallach 24

considered the most important factor in the stimulation of osteoblastic activity and maintenance of bone structure in the treatment of osteoporosis to be the stress and strain of physical activity, even to the point of discomfort. Force is applied through the teeth to the periodontal fibers, then to the lamina dura, and then to the rest of the mandible through the trabecular bone. This force is felt to pass along certain curved pathways called Trajectories, and it is generally felt that the trabecular structure confirms in patterns to these trajectories. The normal forces to the bone are removed along with their resultant trajectories when the teeth are removed. Hence, it is to be expected that remodeling of bone will take place when the teeth are removed. Neufeld found in edentulous patients as compared with dentulous patients that the trabecular wire finer and the cortex thinner, with the cortex over the crest of the ridge being incomplete in all patients and the over all size quite possibly smaller. Neufeld also found that instead of the usual trajectories present in the dentulous mandible, the trabecular pattern in the edentulous mandible was, in general, random, except that in some specimens the trabecular near the crest of the ridge were somewhat perpendicular, suggesting the development of trajectories to the compressive force of a denture. When are the functional factors of frequency, intensity, duration and direction physiologic and when are they pathologic? Where is the dividing line between stimulation and trauma or between disuse and use? The dividing line is not the same for all patients. What to one patient is stimulation conducive to bone formation could well be trauma to another patient, resulting in bone resorption. The functional factors must be interpreted in conjunction with the metabolic and anatomic factors. Disuse atrophy and fracture are example of extremes of functional force.

25

Disuse Atrophy : the use of natural teeth transmits stresses to the supporting alveolar process within a certain range, this is physiologically helpful, serving to increase the density and strength of the alveolar process. However, pressure exerted on a tooth, which is out a line in the dental arch, causes traumatic forces to be transmitted to the supporting process. In this, situation, resorption and reduced density of structure are observed in the bone, with eventual loosening and loss of the involved teeth. When natural teeth have lost and no stimulation is provided in the residual ridge by means of a prosthodontic restoration, the alveolar process, will be lost through disuse. A large protein deficit followed by metabolic derangements develops from disuse. The deficiency is in the formation of the new protein matrix with no disturbance of calcification. A loss of closing free develops because the mucous membrane and the periosteum cannot endure the force once received by the teeth, this loss of internal stimuli and the reduction of closing force are signals for disuse atrophy and a remodeling of the bone in accordance with Wolfs law of Transformation. As Wolfs law states, briefly, that change in room follows change in function and that its change is due to alteration of its internal architecture and external confirmation, in accordance with mathematical laws. Disuse atrophy does not result from the direct loss of nonfunctional bone, but rather from the lack of replacement of bone not needed for function. Some stimuli are present from the action of the denture. But the nature of the stimuli is not normal, the response of the bone varies with the degree, the internal and the tissue tolerance to the stimulation. Reaction of Bone to pressure and tension : An increase of pressure within the limits of tolerance leads to bone apposition. As long as pressure does not interfere with the normal blood supply, nerve supply, and drainage of the bone 26

tissues. The pressure is resisted. However, whenever pressure interferes with the blood or nerve supply or with the venous drainage of the bone, resorption invariably occurs. Normally, the stress of pressure and tension on bone is transmitted through avascular tissue such as the teeth, the condylar articulation, the intervertebral disc, and other joints such structure under pressure are covered by specialized fibrous tissue, fibrocartilage, or hyaline cartilage. If the pressure is against a vascular tissue covering of the bone such as the periosteum, the blood supply to the bone is aggravated and it is a target for resorption. The denture bearing bone has a complex blood supply from two sources, the main supply is internal from the interdental arteries that pass through canals in the interalveolar septa. After extraction, if bone loss that slight, the blood supply is not greatly disturbed. However, if extensive surgical procedure removed large amounts of alveolar bone. The internal blood supply can be vastly altered by the bone callus. The other blood supply comes externally from the periosteum. Arteries from the periosteal network enter the bone as arterioles in the numerous Volkman canals which open from the outer surface of compact prone. Interference with the blood supply leads to bone necrosis, the interference may be due to pressure directly from the bone, or it may be of inflammatory origin. If inflammation is present, a constant internal capillary pressure acts to setup resorptive process. The amount of blood supplied to the prone from within (intrinsic and surgical sequelae) and from without (periosteal network and denture base) can predispose little or great change in bone form. It is tempting to draw definite conclusions about this concept, but it needs further investigation. However, it does seem to offer a logical explanation as to why some patients exhibit so little bone loss and some great loss in a given space of time. OTHERS Dietary Factors : During edentulousness the nutritional requirement are not met with proper attention there will deficiency of the same and this will affect the 27

residual ridge resorption. This usually happens because of impaired masticatory efficiency and to complicate further the alveolar bone is over loaded by complete denture where forces generated are transmitted directly to alveolar prone. Food are classified as a) Protein, b) Carbohydrates, c) Fats, Inorganic elements and e) Vitamins. Protein : Protein is necessary to build and maintain tissue and to supply energy. The necessary daily about requirement of protein is approximately 3 ounce. Aged persons need more than the minimum amount of protein for the maintenance of tissue health. Carbohydrate : They provide the chief source of energy. They are related only, indirectly to bone resorption though association with diabetes and by substitution for more favourable foods. Fat : Fats are organic substance that yield heat and energy and only secondarily build up repair tissue. Vitamins : Diet must contain vitamins for development, growth and function of the body. Vit. A (Carotene) : Deficiency of this causes renal damage by hornification of the tubules. This damage results in the abnormal loss of phosphorous and the tubules lose the capacity for reabsorption. The imbalance of the Ca-phosphorous ratio leads to osteoporosis. A lowering of Vit. A also has an effect on the osteoblasts so that they engage in disorderly and uncontrolled activity. The cells adjacent to the bone modulate to osteoclasts and become active. There is a damage of Hyper vitaminosis A, but experiments are inconclusive as to the mechanism. Some reports indicate an acceleration of matrix remodeling while others seem to conclude that excess vit. A accelerate 28 d)

the activity of the osteoclasts. The general function of Vit. A in regard to bone is its influence on the activity and position of the osteoblasts and osteoclasts. Vit. B Complex : Vit. B complex produces effects in bone similar to a protein deficiency Chase reported degeneration of bone, enamel and dentin in rats on a B-complex deficiency diet. Osteoporosis of gingival inflammation were reduced in dogs by withdrawal of nicotinic acid. This condition was corrected by addition of this part of the B-complex to diet. Vit. C : The collagen content of prone is reduced in vit. C deficiency the lossening of teeth in survey is due both to prone resorption end to disorganization of the periodontal fibres and members, the periosteum is affected in a similar way. It thickens, and the cells appear immative and resemble fibroblasts. This condition may make the periosteum more easily injured by the denture base sot that inflammatory process are triggered by the denture base at lower pressure levels. Vit. D : Deficiencies of Vit. D disturb the Ca-phosphorous balance and promote prone resorption. Habits : Habits such as food intake, masticatory, bruxism, sleepswith denture, holds pipe, sucks fingers, bites nails, nibbles with anterior teeth etc. can affect RRR. Biological factors : such as tissue health, saliva content, oral hygiene, oral bacterial flora, drug or alcohol intake. DIAGNOSTIC AIDS TO DETECT RRR Many techniques have been used to establish that bone is in fact being turned over.
1.

Radiographic : This procedure is widely used to detect bone resorption and formation phenomenone by taking periodic radiographs. 29

2.

Tetracycline labeling : In this tetracycline is injected into the body through oral or pariental administration and should be repeated the same after every week for 5 weeks. This tetracycline is taken up by the bone, only in the new sites of bone formation tetracycline can be readily identified in the bone, because the resultant tetracycline calcium chilate formed is fluoroscent and can be viewed by fluorescence microscopy.

3.

Mercury porosimetry : Osteocytes are also capable of bone resorption (i.e. periosteocytic lacunar bone resorption). This is evaluated by enlargement of osteocyte lacunae. Therefore, inorder to determine the quantitative importance of osteocytic resorption. A method known as mercury porosimetry was used to makes a comparison between osteocytic and osteoclastic bone resorption. In this method mercury is introduced into pores by pressure and a measure of the pore volume as a function of pore diameter is obtained. Since osteocyte lacunae, canaliculi, and vascular canals constitute a system of pores, this method can be applied to measure the volume of different classes of bone pores. Thus with this method it was able to quantitate osteocyte lacunae canalicular volume, which enlarges as a result of osteoclastic resorption and vascular canal volume, which enlarges as a result of osteoclastic resorption.

PATTERN OF BONE CONSIDERATION

RESORPTION

AND

ANATOMICAL

Gross anatomic studies of jaw bones have revealed a wide variety of shapes and sizes of residual ridges. In order to provide a simplified method of categorizing the most common residual ridge configuration. It has been described as a system of 6 patterns of residual ridge forms have been described. Order I Pre extraction Order II Post extraction Order III High well rounded. Order IV Knife edge 30

Order V Low well rounded Order VI Depressed or invested Even among individuals of the same sex there exist large variations in the morphologic characteristics of the residual ridge and associated bones, and these can be related to their original anatomic features. There are however, certain patterns of resorption and some persistant anatomic structures that can be recognized from one case to another. These structures are palpable when they become protruberant, they are the genial tubercles, the external oblique line and the mylohyoid crest for the mandible or for the maxilla, the nasal spine, and the pterygoid plates. The usual changes that take place after dental extraction are those of a ridge initially wide enough at the crest to accommodate the natural teeth that changes to one that is narrow and sharp, then-flat, and finally concave. These four stages of resorption correspond to the classification of residual ridges unable to adequately maintain denture in place. Group I : High, crestal muscles over non-resorbed ridge Group II : Sharp atrophic residual ridge. Group III : Absence of residual ridge and resorption to the level of the basal bone. Group IV : Absence of residual ridge and part of the basal bone. Mandibular changes : In the anterior region one can observed progressive deterioration of the lateral bone profile, the angulation of the anterior slope, and the ridge form, the profile is modified from a pear-shaped appearance to a pointed one. Soon after teeth are extracted, the anterior slop angulation gradually loses its perpendicular position with the mandibular plane as the crest of the ridge moves backward the 31

ridge leads to a flat and round basal bone shape and more rarely to a concave form where the basal bone itself is involved. In the premolar molar region, bone loss is more rapid than anteriorly because of the resorptive nature of the posterior dorsum and a lower position of reversal lines. Hence bone resorption of the basal bone is more frequent in this region. Typical patterns of resorption are recognized and outlined by the presence of this structure that resist resorption, the external oblique line and the mylohyoid crest, the concavities seen from the different planes may be present; a lateral dishing of the crest from the cuspid to the retromolar region and a longitudinal midbody concavity. The dishing of the crest is best revealed by the lateral cephalogram. In more advanced stages of atrophy these posterior bilateral concavities are more pronounced, with erosion of the basal bone, they may become associated with a roundly shaped anterior basal bone, a frequent finding, described as the sphenoid anteriors basal bone with posterior concavities. On the medial side of the residual ridge the bone contour forms a gradual slope toward the mylohyoid crest. In very advanced stages, the concavity occupies the major portion of the dorsum of the corpus. It is more commonly located between the dense external oblique line and the mylohyoid crest. The position of the teeth in the alveolar basal bone complex may also play a role in these changes the lingual inclination of the molars and the more facial position of the premolars, canine and incisors, which result in the presence of more bone on the lingual side of their roots. Contribute to the frequent occurrence in resorbed mandibles of another structures, the paralingual crest. This palpable crest, originating at the myolohyoid crest, itself extending anteiorly in a downward direction, may become a true lingual shelf. It may fuse with another structure that becomes protuberant and palpable in advanced stages of atrophy: the genial tubercles. 32

Four stages of ridge resorption and classification of deficient residual ridges:

33

Maxillary changes : Patterns of resorption in the maxilla differ from those in the mandible. Maxillary ridge resorbs usually more evenly than the mandibular ones because of larger denture bearing areas, with the palate providing a more equal distribution of mechanical forces. When the anterior maxillary bone disappears at a faster rate than the posterior part, it is more often due to excessive forces originating from natural mandibular incisors and inadequate posterior prosthetic support. The lateral cephalogram uncovers an anterior maxillary slope that represents the external side of the triangle formed by the meeting of the palate with the anterior ridge. The angulation of this slope relative to the palatal plane persists much longer throughout the different stages of atrophy than in the opposing jaw. This particularly could be explained by the natural protrusion of the anterior maxilla, which is designed to hold incisors that are normally inclined at 110 degrees with the palatal plane. After dental extraction and during ridge remodeling, the posterior drift of the anterior crest does not become as pronounced as in the mandible because of this advantageous bony artchitecture. An anterior ridge form persists for a longer period time, the angulation of the slope is affected only in advanced stages of atrophy when the triangular form disappears and the crest reaches the same level of the palatal bone or even below this level. In these instances there is projection of the nasal spine.

34

Residual anterior maxillary triangle and persistence of ori anterior bone contour slope throughout different stages of atrophy In the posterior region progressive reduction of the width of the maxilla takes place as the ridge resorbes. This process is related to the outward inclination of the maxillary premolars and molars to accommodate for the lingual angulation of the mandibular teeth, and to the presence of thin buccal plates more susceptible to resorption than the thicker palatal ones. The pterygoid plates will become palpable, in advanced stages of atrophy, their extremities being located below the palate. Intermaxillary changes The relationship that existed between the two maxilla when teeth were present might have undergone a change after ridge resorption, with an increase of interridge distance as the most obvious change in the vertical bone, especially in the anterior region. Sagittal and anteroposterior relationship are also affected. An inverse ridge relationship and a pseudo prognathic condition will develop with advanced stages of atrophy. The maxillary ridge will be reduced in size, whereas the mandibular one will be expanded, when ridge resorbtion reaches the level of the basal bone. This transformation is favoured by the natural architecture of both maxilla, the circumference of the crest of the maxilla being longer than the circumference at its base because of the outward inclination of the teeth; the reverse is present in the mandible where the teeth and their supporting tissues are seated over a wider bone base.

35

Soft tissue changes Soft tissue changes also occur after teeth are lost and dentures are worn. A crestal scar bond representing the remnants of the attached gingiva is usually present all along the crest. It is more prominent and hyperplastic when some residual ridge remains. It then acts as a protective cushion between the sharp residual ridge and the denture base. Heavy fibrous tissue will develop in the tuberosity regions, especially when maxillary molars were removed at an early age or when the maxillary denture was not rebased in the first years after teeth were extracted. This tissue puts up the space left by lost bone. ANATOMICAL CONSIDERATION Mental foramen becomes more close to the denture bearing areas, the alveolar process decreases in size, the change of denture impingement on the mental nerve increases with bone loss and the nerve is more vulnerable to the injury during surgical grafting or implantation procedures. Progressive bone loss leaves the nerve near superior surface of the mandible. The ultimate result of complete alveolar bone loss is concave superior surface of the mandible. This concave surface represents the upper surface of the cortical plate of the mandibular inferior, border. In severe cases, the genion

36

tubercles may be superior to the crest of the mandible, pressure on the mucosa on this area cause sharp pain. Muscle attachments such as buccinator, mentalis, mylohyoid and genioglossus do not migrate significantly, RRR leaves the muscle attachments close to the crest of the ridge muscle function will often lift the muscle and overlying mucosa above the level of the alveolar ridge, thus reducing the amount of the alveolar bone exposed in the mouth. As the bone loss progreses in the maxilla the palatal vault becomes relatively more shallow and redundant soft tissues forms labial to the alveolar crest. The nasopalatine neurovascular bundle may end up on the crest of the ridge or anterior to it. Impingement on this nerve by the denture may occur. However, this is less often a problem when compared to the tough mental nerve. The shape of the maxilla during RRR is dictated by as many of the factors as in the mandible. In case where lower anterior teeth occlude with the upper complete denture. RRR occurs in the anterior ridge where height decreases to a point of dehiscence between the mouth and the nose. This usually occurs at or just posterior to the piriform rim of the nose. The anterior nasal spin may be almost with the level of the alveolar crest. RRR in the anterior maxilla mostly occurs on the labial and inferior aspect of the alveolar ridge so that the crest moves posteriorly. Upper lip support is progressively lost as anterior maxilla decreases in size. This combined with the relative anterior movement of the mandibular ridge results in an increasingly Class III facial form and ridge relationship. Posteriorly, as the maxillary tuberosity decrease in height it approaches the level of the mucosa that is draped from the muco-gingiva junction on the posterior aspect of the maxillary tuberosity i.e. hamulus. This change oblitrate the posterior slope of the tuberosity. As the mandible becomes smaller as the teeth removed, resistance to the fracture is reduced. Fracture in extremely small edentulous mandibles are especially omnions, because of the lack of bone mass for fixation and due to the changes in blood supply. As RRR occurs, major source of blood supply to the mandible change from centrifugal to centripetal 37

(periosteal) the inferior alveolar vessels become smaller and less significant in the nourishment of the mandible. Therefore, the surgical procedure that elevate the mandibular periosteum compromise the blood supply more as the mandible becomes smaller. CLINICAL SIGNIFICANCE Clinical observations indicate that excessive alveolar bone resorption can be caused by physiologically intolerable forces produced by functioning complete dentures. Changes which have to be considered and taken care while fabricating the complete denture can be grouped into five major categories. These are: 1) Appearance (facial and teeth). 2) Efficiency of mastication. 3) Phonetics. 4) Pain and discomfort (Alleviated or initiated, imaginary or real) and 5) Prone and tissue changes. Appearance Commonly seen men are taller, have greater facial heights and just more jaw bone to resorb after dental extraction. The ratio of potential units of bone to resorb to the years of resorption acts in their favour. But one should not assume. However, that men have an advantages in treatment over women because men usually have more bone left after the same number of years of denture wear. Not only the volume of bone but also its form must be examined. A large residual basal bone does not necessarily means a more favourable ridge for denture construction or one superior to a but for the convenience of understanding and implementing certain parameters so that the proper care is taken for the prevention of the further residual bone resorbtion. 38

Thus, following Devans scientific words. Its perpetual preservation of what remains of the oral masticatory apparatus rather than a meticulous restoration of what is missing. We start with clinical consideration for RRR from impression procedure

Impression Procedures
Before impression procedure, care has to be taken on selection of custom made trays. If the tray selected is too large, it will distort the tissue around the borders of the impression away from the bone. If it is too small, the border tissues, will collapse inward onto the residual ridge. This will reduce the support for the denture and prevent the proper support of the lips by the denture flange. As we are know the commonly used two procedures for the final impression procedure are: 1. Minimal pressure technique. 2. Selective pressure technique. 1. The minimal pressure technique with mucostatic principles ignores, the value of dissipating masticatory forces over the largest possible basal seat-area. If for example, the patient could develop masticatory force of 30lb, it is evident that the larger the basal seat area, the less force would be exerted on each square millimeter of underlying mucosa furthermore, the form of the mucostatic denture minimizes the retentive role of the musculature. Today, a large proportion of dentists make impressions with minimal pressure in order to avoid distortion of the mucosa and ridge areas which may undergo considerable pressure otherwise. 39

2. The principle of this procedure making impression is based on the being that the mucosa over the ridge is best able to withstand pressure, as compared to the mucosa covering the midline is thin and contains very little submucosal tissue. Many fine dentures are made according to this principle of selective pressure and definitive judgement on the merits of this approach must be deferred. It must be emphasized, however, that this technique demands firm, healthy mucosal covering over the ridge. If flabby ridges exist, than decision to make mucostatic, functional or selective pressure all have to be considered. It can be argued that tissue tissue will become displaced in occlusal function and therefore, should be improved in a functional state. However, as with all functional impression techniques, the amount of functional placement is unknown, the functional movement probably would not be the same in extent or direction with each functional load because the patient is more often at rest than in occlusal function, it is not practical to make the impression of the tissue in a functional state. The true mucostatic theory as it relates to impression making may find advocates who are dealing with the hypermobile ridge crest. The principle of pareals law as related by Page. However, would have questionable value here because the excessive tissue movement encourages denture base movement. This will prevent the equal distribution of force that the true mucostatic principle purposes. 3. The use of a combined mucostatic and functional impression technique, the selective pressure impression technique seems to be the most advantageous for the hypermobile ridge crest, as with most complete denture impressions, the hypermobile tissue itself would be recorded at rest with functional placement of border tissue to enhances denture retention and stability. Many techniques have been proposed depending 40

upon the severity of the redundancy, and it is not the intent to suggest a specific impression technique here Jaw relation Correct recording of vertical and horizontal relations are equally important for the preservation of residual bone resorption. In horizontal relations unless centric relation is established, properly, the mandibular teeth will not occlude properly with those on the maxillary arch, thus proper occlusion is essential to the health of bony support. Otherwise during eccentric movement it causes pressure on bone due to failure of the factor stability. Hence cause resorption of bone. Loss of occlusal vertical dimension the loss of proper occlusal vertical dimension after the insertion of complete dentures result on the triggering of a cyclic series of events detrimental to the health of the residual alveolar ridges. Due to excessive interarch distance, because premature striking of teeth cause recurring trauma to the tissue (i.e. bone and mucosa) and longer leverage, making the denture more outward to manipulate and more easily displaced. Whenever an excessive amount of bone has been lost from various causes (sch as periodontal disease, ill fitting denture that have been worn for many years, partially edentulous months, especially with all the mandibular posterior teeth gone), it is possible to reduce the denture space an undesirable amount. In narrower knife-edged ridges that cannot be made comfortable in any other manner may be treated by reducing the occlusal vertical dimension to trauma and sorners. Selection and Arrangement of teeth : 41

Occlusal form : The form of the occlusal surfaces of artificial teeth, whether of anatomic, non anatomic or 0 degree configuration, must have some effect on chewing efficiency and force tending to affect the underlying tissues. The arrangement of individual teeth in complete denture include a myriad of possibilities ranging from a flat occlusal plane with 0 degree teeth to a curved configuration which allows anatomic teeth to glide and pass over each other in close harmony with mandibular movements. Advocates of cuspless flat plane occlusion, reverse pitch occlusion, and variations of the reverse pitch occlusion i.e. (pleasure curve) consider such occlusal schemes to be effective in helping to preserve the underlying ridges. Proponents of anatomic teeth for complete dentures emphasize careful settling and selective grinding of the teeth to minimize lateral stresses and the resulting tissue trauma. Placement of the posterior teeth. This factor also plays an important, role while arranging the posterior teeth. It is said that by placing the posterior teeth on the crest of the ridge, the stress distribution is equally distributed and reduces the bone resorption. Special attention has to be given in patient suffering from diabetes, or the above mentioned systemic diseases. Tooth material : As it is said the material from which the denture teeth are made may have some effect on the forces transmitted through the denture base material to the supporting ridges. While a complete denture is given against a natural dentition. Ideally, acrylic teeth are preferred as the porcelain are brittle material causes attrition of the natural teeth and if porcelain teeth are used than the occlusal surface have to be covered by gold to prevent much wear and tear. A very dangerous and traumatic combination of teeth is acrylic resin posterior teeth on one or both arches and upper and lower porcelain anteriors. 42

Because of the abrasion of the posterior teeth, the anterior teeth develop interfering contacts during mastication that will continually traumatic the anterior part of the upper and lower denture foundation. This is potentially dangerous to the health of the supportive tissues and should always be considered when selecting the tooth materials. Size of posterior teeth: the selection of the proper tooth size or mold is based upon D the capacity of the ridges to receive and resist the forces of mastication and space available for the teeth and the esthetic requirements. We considered is the first one. In most complete dentures the lower ridge offers less support to the forces generated by the occlusal surface of the teeth. Its smaller area of support and more rapid resorption pattern progressively narrow and reduce the height of the lower ridge. Because of this, the use of posterior teeth should favor the lower ridge. For these reasons the determinants for selection will be based on the lower ridge. When the lower ridge is strong, well formed and covered by a generous area of attached masticatory (keratinized) mucosa, the full space available can be used because this ridge has the capacity to tolerate the forces of mastication. When the ridge is weak, resorbed, and covered by only lining mucosa, then the size of the posterior tooth should be smaller. This will limit the occlusal surface, which in turn will minimize the forces directed to such a ridge. The inverse ridge relationship that may result from severe loss of bone will create problems in constructing the denture and placing teeth. In order to use the buccal shelf, a stable dentin bearing area, the posterior mandibular teeth must be placed closes to the vestibular side and the maxillary teeth outside the ridge it one wishes to correct the crossbite relationship, both dentures consequently will be mounted outside their original bearing areas.

43

Dentin base deformation : Forces generated by reaction at the occlusal surfaces of the denture teeth must be transmitted to the denture base prior to the ultimate dissipation of these forces in the supporting residual alveolar ridges. For degenerative denture ridge patients, there are three types of denture bases: 1. Resin base. 2. Cast metal base. 3. Processed, resilient lined denture bases. Sharry, Ashow and Herper used strain sensitive lacquer to study deformation patterns in bone on skulls (with dentures) when the mandible was pulled into lateral and protrusive positions. More deformation was caused under the dentures with anatomic tooth forms than with nonanatomic forms. Studies employing electrical strain gauges embedded in various type denture bases have been conducted to measure deformation occurred during mastication with anatomic than with nonanatomic teeth and acrylic resin denture bases deformed much more than did metal bases under similar situations. One study demonstrated that reducing the occlusal surface area had no significant effect on deformation whereas reduction of the cusp angles significantly reduced the deformation of the mandibular denture base. After curing the dentures the lab remounting has to be done and selective grinding for working balancing contacts and for protrusive balance has to be carried out in order ot remove any interference. Lastly after insertion of the denture, the patients have to be recalled on a regular schedule correct any existing occlusal disharmonies an encouraging the patient to remove this dentures upon retiring.

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Masticatory apparatus therapy Older edentulous patients frequently suffer from problems involving the temporomandibular joints and imbalance with spasms of the muscles of mastication. These conditions should be treated, alleviated, and corrected if possible before jaw recordings are attempted and new dentures constructed. Fortunately, this can accompany the tissue treatment. When these problems exist, the old dentures are duplicated, the duplicated dentures are then lined with soft resin for impression purposes. The soft lined dentures are then articulated with a face-bow and centric relation records. The upper denture is converted via a laboratory duplicators to a self curing resin base, the occlusion is surveyed, and if nearly correct and with an acceptable vertical dimension, the dentures are ground in to a balanced occlusion. When the occlusion is less than acceptable, the lower denture is removed from the cast and the lining removed the lower denture is positioned into centric occlusion against the upper denture and luted to it with sticky wax. The lower cast is lubricated soft lining resin is placed on the basal surface of the lower denture, the articulation is closed to a predetermined vertical dimension and the resin is allowed to cure, the sticky was is removed, the occlusion is checked, and mucin imperfections are eliminated. By this means, the old lower dentures which has often moved forward into a prognathic relation with collapsed vertical dimension can be corrected. In doing so we have supported the mandible and maxilla and established a good centric occlusion and occlusal vertical dimension we have relieved the strain on the musculature and the temporomandibular joints. For a short time, there may be distress in the TMJ or the musculature, this will cause some resolutions in the apparatus and a shift in the occlusion with successive treatments, the lower denture can again be relieved and the repositioning process repeated, progressively obtaining a better centric relation record and desirable vertical dimension such treatment may solve the emergency problem quickly while preparing the patient for new denture. 45

SURGICAL TREATMENT CONSIDERATION Usually the problem associated with denture wearer is one, bone loss that affects ridge form and increases muscle interferences. Before hydroxyapatite become available this loss could not be replaced, except in extreme atrophy when ridge augmentation with bone graft was used, with all the uncertainties of resorption and inadequate gain of ridge form. Pre prosthetic reconstructive surgery was limited mainly to ridge extension procedures with muscle reattachment, the outcome of this surgery was dictated by the contour of the residual bone. These procedures were very successful. If there was not atrophy, such as in group I patients, or if the bone loss has affected more the width from the height of the residual ridge, such as in certain group II cases. But when very little ridge was left or when only the basal bone remained and the contour was deficient little gain could be expected from extension techniques unless extensive detachment of the chin and tongue musculature was done. Hydroxyapatite has opened up a new in preprosthetic reconstructive surgery. It offers numerous possibilities. This material not only can be used to reconstruct an ideal ridge form with less relationships with the help of dependable techniques. Although, many patients with poor residual alveolar ridges wear complete dentin successfully, other experience varying degree of difficulty. Most patients complaints are related to the mandibular C. D. longitudinal studies indicate that the bone loss associated with the mandible is four times greater than that associated with maxilla. In extreme atrophy the mandibular denture can impinge upon the contens of the mental foramen and / or the inferior alveolar nerve and cause discomfort and parasthesia of the lip. An extremely atrophic mandible is also more susceptible to fracture. These problems are especially significant in relatively young patients who can expect to wear prosthesis for many more years. 46

Those have been many attempts to mitigate the problem by various materials of treatment that incluide: 1) Soft tissue vestibuloplasties to increases the relative height and extent of the denture foundation. 2) Subperiosteal or endosteal implants to improve comfort and retention of the denture and preserve the remaining mandibular bone. 3) Augmentations with alloplastic materials such as proplast calcium aluminate ceramic material to increase the vertical height of the mandible and. 4) Augmentations with homogenous and autogenous bone and cartilage in different forms and combinations to increase the vertical height of the atrophic mandible.

Tissue augmentations for atrophic mandibles may be divided into the following categories: 1) Implantation of freeze dried homogenous bone and cartilage. 2) Implantations of autogenous cancellous bone and /or particular to marrow in conjunction with some form of tray. 3) Implantation of block sections of autogenous ilac crest or ribs cortical and cancellous bone. According to the surgical procedures to be followed by the RR according

to Roger Masella classified as: Group I High crestal muscles and non resorbed ridge: Difficulties in achieving stability and retention are not always related to a deficit of bone. Certain patients with ridges that have resorbed very little, 47

especially the mandibular ridge cannot be helped a conventional prosthodontic approach. The tonicity of the muscle and / or their attachments at the crest of the ridge prevent the development of the necessary extension of buccal and lingual flanges needed for stability and retention. Ridge extension procedure is vestibuloplasty may be benefit this group twice the anteriors slope of the mandible is favourable to again of denture bearing area. Group II painful atrophic ridge Most of the problems incomplete denture prosthodontics are of this type. Usually the ridge has resorbed until the crest made of sharp lingual or palatal cortical plate, covered by a redundant of tissue that moves with palpation and is painful to pressure. Many non surgical attempts at treating the hyperplastic (flabby) ridge have been attempted they range from mucostasis impression to the use of tissue conditioners. These procedures have not only partial success since the mucoperiosteum of sharp bony spicules remains. Group III Absence of residual ridge : Many patients with ridges that have been reduced to the basal bone may have better masticatory function than those patients in the two previous groups, the mandibular denture rests on a painless flat or frequently serves to stabilize the denture may exist these patients with above average muscles coordination and the capacity to provide the equilibrium of the orofacial muscles necessary to retain the denture in place, may benefit from the refinement of excellent prosthodontic treatment using a conventional approach. However, for those group III patients with a severe functional handicap a ridge augmentation with implements procedure should be considered.
1.

Vestibuloplasty : The literature is replete with various techniques for vestibuloplasty. These range from the early technique of ridge extension with secondary epitheliazation to techniques that emphasize to importance of including the attachments of the muscles of the floor of the mouth in 48

the dissection. The original description of the total lowering of the floor of the mouth with vestibuloplasty and split thickness skin graft was presented by Obwerzer in 1963 which still serves as the standard approach. Until the adherent of predictable implant treatment, augmentation procedure of the edentulous maxilla and mandible focused on reconstruction of lost R.R and archform for retention of conventional dentures. Today, our goals for augmentation and reconstruction have broadened because implant utilization with its advantages of increased support for function and bone preservation with time, has become the preferred endpoint of reconstruction, the placement and growth of viable, healthy mature bone in areas of potential implant placement are now our primary concerns. Good ridge form and / or soft tissue extensions are still preferable but are not as critical if an adequate number of implants are available to support prosthetic. Previously used large scale secondary soft tissue procedures for improving the denture bearing area, such as reconstruction of the floor of the mouth and buccolabial vestibule (vestibuloplasty) with split thickness skin grafting are loss frequently necessary when implants are first soft tissue manipulates is addressed relative to implant procedure and is usually more localized, with much less patient morbidity implants have become or great step forward in our progress in treating the edentulous maxilla mandible.

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Maxillary augmentation for utilization of implants: The severely resorbed maxilla requires bone grafting of the more common techniques described for maxillary grafting that have been used with success are: 1. Corticocancellous horseshoe graft obtained from the ilium and fixed to the maxilla with osteointegrated implants. 2. LeFort I down fracture, with an interpositional cortico cancenllous graft obtained from the ilium and placed into the antrum and anterior nasal floor. 3. Corticancellous onlay block graft obtained from the ilum and fixed to the remaining alveolar and / or maxillary sinus floor with wires or screws. 4. Particulate autogenous corticocancellous ilium (ACI) mixed with porous hydroxyapatite (HA) particles and grafted in onlay fashion and / or into the maxillary antral floor / sinus lift procedure. Mandibular augmentation Mandibular augmentation is needed in group III and II cases and mandibular augmentation for implant utilization is needed when severe resorption will not allow acceptable fixture height in position because of lack of adequate bone. Augmentation also is indicated when population of the implant sites may lead to mandibular fracture or when pathologic fracture is a concern. The permanence of the bony reconstruction of the mandible has historically been a problem. pichler and Traunec, in 1948 whole that clementschitch may have been the pioneer in the construction of the alveolus of the mandible using blocks of autologous ilium. Many other followed, using autologous ilium, but it was found that the grafted area tended to resorts after a four months and had often completely disappeared. 50

After a few years Obwegeser and Co-workers, introduced the application of autologous eris in this problem. this graft tended to last somewhat longer. Thus, the grater proportion of cortex to spongiosa of rib appeared to suggest that the more cortical bone present in the graft, the longer the grafted area tended to remain, the grater amount of cortical bone results with a prolonged resorption and replacement phase while the graft changes to viable lamellar bone. It appeared possible that if a non resorbable substance could be substituted for the function of the cortical bone, the highly osteogenic autoglosus cancellous bone might form a composite that could last indefinitely Icent and coworkers appeared to validate this hypothesis by adding dense via to autogenous cancellous bone. This mixture revealed less than 15% resorption at 4 years after grafting. Thus, the problem of the retention of the grafted bone for strength of the mandible has substantially been solved by the addition of dense HA to the bone graft material. However, when this type of grafting system is used for implant sites when the implants are to be placed after graft maturation, the dense HA presents a problem on that it is difficult to through it. Therefore, dense HA and bone are best used when a graft is to be placed around a implant. Another splints to substitute the porous form HA for the dense form as porous can be drilled. It was generally considered that the porous form of HA would be long lasting it is sometimes reform non resorbed. Hence it appears appropriate to use porous HA mixed with the bone graft in areas where implants are to be placed and dense HA mixed with the bone graft when strengthening only is require.

CONCLUSION
Resorption of alveolar bone seems inevitable when teeth are lost, yet variability exists between persons. Both between and within the jaws and over time. It would seem that bone that has undergo higher rates of resorption initially

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will continue to resorbs excessively compared with bone that has undergone lower rates of resorption. Metabolic differences are undoubtedly most significant in the response of a given individual to a given stress and account for the variations among individuals within the same individual at different times. The state of knowledge is so inadequate that there is no single test or set of criteria which can be used to determine whether a given patient has a good bone factor or not. We must rely on clinical judgement. Which is notoriously poor we revaluate the general nutrition, metabolism and hormal activity of the patient, sometimes age or sex provides clues. A dental history of or clinical evidence of inordinate previous bone loss may suggest a poor bone factors but such bone loss must be evaluated in light of the anatomic functional and prosthetic factors. The findings although not statistically significant, suggest that clinical judgement of prosthodontics depends not only on a profound. Understanding of the myriad of significant technical factors but also on the understanding of the complex interrelationship of these technical factors with anatomic metabolic, and functional factors. This is what makes prosthodontics challenging. This is what makes prosthodontics fun.

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REFERENCES
1) Lammie G.A. : Reduction of the edentulous ridges. J.P.D., 10 : 605-611, 1960. 2) 3) Sobolik C.F. : Alveolar bone resorption. J.P.D., 10 : 612-619, 1960. Atwood D.A. : Some clinical factors related to the rate of resorption of residual ridge. J.P.D., 12 : 411-450, 1962. 4) Ortman H.R. : Factors of bone resorption of the residual ridge. J.P.D., 12 : 429-440, 1962. 5) Atwood D.A. : Reduction of residual ridges : A major oral disease entity. J.P.D., 26 : 266-279, 1971. 6) Fenton D.H. : Bone resorption and prosthodontics. J.P.D., 29 : 471-413, 1973. 7) Keisey L.L. : Alveolar bone resorption of prosthodontics. J.P.D., 25 : 152161, 1973. 8) Neufeid J.O. : Changes in the trabecular pattern of the mandible following the loss of teeth. J.P.D., 8 : 685-697, 1958. 9) Wyatt C.L. : The effect of prosthodontic treatment on alveolar bone loss : A review of the literature. J.P.D., 80 : 362-364, 1998. 10) 11) Atwood D.A. : Bone loss of edentulous alveolar ridge. Kapur K.K. : The effects of complete denture on alveolar mucosa. J.P.D., 13 : 1030, 1963. 12) Turck D. : A histologic comparison of the edentulous denture and non denture bearing tissue. J.P.D., 15 : 419, 1965. 53

13) 14)

Pietro Kovski : The bony residual ridge in man. J.P.D., 34 : 456, 1975. Enlow D.H. : The remodeling of the edentulous mandible. J.P.D., 36 : 685, 1976.

15)

Paul Mercier : Ridge reconstruction with hydroxylapatite. J. Oral Surg., 505, 1968.

16)

Baylink J.D. : Systemic factors on alveolar bone loss. J.P.D., 31 : 486, 1974.

17)

Leka Jahangeri : Current perspectives in residual ridge remodeling and its clinical implications : A review. J.P.D., 80 : 224, 1998.

18)

Curtis A.T. : Autogenous bone graft procedure for atrophic edentulous mandibles. J.P.D., 38 : 366, 1977.

19)

Wendt. C.D. : The degenerative denture ridge-care and treatment. J.P.D., 32 : 477, 1974.

20)

Winkie R. : Essentials of complete denture prosthodontics.

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CONTENTS
1) Introduction 2) Normal Alveolar Bone Physiology 3) Tooth Extraction, Wound Healing And Formation Of The Residual Bone 4) Bone Remodelling Process 5) Histological Observation Of Residual Bone Resorption 6) Factors Affecting Residual Ridge Resorption 7) Diagnostic Aids To Defect Rrr 8) Pattern Of Bone Resorption And Anatomical Consideration 9) Clinical Significance 10) Conclusion 11) References

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CONTENTS
Introduction Functions of Maxillofacial Structures Establishment of Vertical Maxillomandibular Relations for Complete Dentures Methods of Determining Vertical Relation Physiological Methods Phonetics As a Guide Tests of Vertical Jaw relations with occlusion rims The speaking method The closest speaking space and the free-way space Technique with existing dentures Technique without records or dentures Phonetics in orientation of anterior teeth Labiodental Sounds Dental and alveolar sounds Palatal and velar sounds Patient adaptation in phonetics Palatal contour of the Denture Palatography for proper palatal contour Discussion Conclusion

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