Trauma; PreprostheticSurgery

A classification of the edentulous jaws

J. L Cawood and R. A. Howell." A classification o f the edentulous jaws. Int. J. Oral Maxillofac. Surg. 1988; 17:232-236 Abstract. A classification of the edentulous jaws has been developed based on a randomised cross-sectional study from a sample of 300 dried skulls. It was noted that whilst the shape of the basalar process of the mandible and maxilla remains relatively stable, changes in shape of the alveolar process is highly significant in both the vertical and horizontal axes. In general, the changes of shape of the alveolar process follows a predictable pattern Such a classification serves to simplify description of the residual ridge and thereby assist communication between clinicians; aid selection of the appropriate surgical prosthodontic technique; offer an objective baseline from which to evaluate and compare different treatment methods; and help in deciding on interceptive techniques to preserve the alveolar process. An awareness of the pattern of resorption that takes place in various parts of the edentulous jaws, enables clinicians to anticipate and avert future problems.

J. I. C a w o o d ~ a n d R. A. H o w e l l 2 ~Maxillofacial Unit, Royal Infirmary, Chester, UK, 2Liverpool Dental Hospital, Liverpool, UK

Key words: classification; edentulous jaws; preprosthetic surgery. Accepted for publication 5 January 1988

When considering preprosthetic surgery of the edentulous jaws, it is essential that both the surgeon and prosthodontist possess a detailed knowledge of the changing anatomical form of the jaws, following tooth loss. To date, attempts to describe and classify these changes are unsatisfactory,, 2, 4, 5. They have been either too subjective or incomplete. Several studies refer to changes in vertical dimension occurring in the anterior region of the edentulous mandible, but make no reference to the changes in the horizontal dimension or to changes occurring posteriorly. There is a paucity of objective data relating to the bony changes in the edentulous maxilla. For these reasons, the authors undertook a study firstly to measure the changes in shape of the edentulous jaws and secondly to classify these changes if possible.
Material and M e t h o d s

processes based on the presence of reversal lines, which delineate the most inferior extent to which alveolar reduction is likely to progress. This subdivision coincides with the

line connecting the mental and mandibular foramina (Figs. 1A, B). Three points S, M and K on this line were selected. S indicates the intersect through symphysismenti with a horizontal line connecting the mental foramina, M the mental foramen and K the mid-

1A 2A

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A randomised cross-sectional study of the Greig Collection was carried out at the Royal College of Surgeons of Edinburgh which comprises 300 dried skulls.
Mandibular study

Fig. 1. (A) Remodeling changes (shaded) in

the mandible in relation to loss of the teeth (after ENLOWet al.3). (B) The line connecting mental and mandibular foramina delineates the boundary between the alveolar process and basalar process. 3 reference points S, M and K were selected. (B).
S M K

As demonstrated by ENLOW et al.3, there is a subdivision between the alveolar and basalar

Fig. 2. Measurements of the height (A) and width (13)of the alveolar process and basalar process were taken at points S, M and K.

A classification of the edentulous jaws

point of the line connecting the mental and mandibular foramina. Twelve variables were analysed, namely, height and width of alveolar and basalar processes at points S, M and K respectively (figs. 2A, B). The mandibles were grouped into 4 categories. Group 1 were dentate, groups 2, 3 and 4 were edentulous with moderate, severe or extreme resorption respectively. Group effect was determined by 1-factor 3A
IVIIV] S VERTICAL GROUP r EFFECT ALVEOLAR BASAL

233

analysis variant. Associations between variables were measured using Pearsen's productmoment correlation co-efficient and by Spearman's rank-correlation co-efficient.

whereas the m e a n value of basal m e a s u r e m e n t s are n o t significantly different, see also Tables 1A, B.

Results
As c a n be seen in Figs. 3 A - F , the m e a n values o f alveolar m e a s u r e m e n t s are significantly different between groups,

Fig. 3. Differences between mean values of

mandibular measurements for groups. S vertical (A); S horizontal (B); M vertical (C); M horizontal (D); K vertical (E); K horizontal

(F).

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234

Cawood & Howell Table 3A. Vertical maxillary measurements (mm) (n = 30) Anterior I-C mean SD 11.20+1.30 6.77+_2.01 1.09+_ 1.45 alveolar Table 3D. Horizontal maxillary measurement (mm) (n = 30) Group 1 2 3 I-GP mean SD 39.60+-2.70 39.23+_2.62 39.00+_2.28 basalar

Maxillary study

O f the 4 processes o f the maxillary bone, the alveolar a n d palatal (basalar) processes are relevant to this study. The incisive f o r a m e n (I) a n d the greater palatine f o r a m i n a ( G P ) are located at the j u n c t i o n o f the alveolar a n d b a s a l a r processes. Figs. 4 A - D show the maxillary alveolar a n d b a s a l a r linear m e a s u r e m e n t s r e c o r d e d in the vertical a n d horiz o n t a l axes. T h e 11 variables s h o w n in Table 2 were analysed to d e t e r m i n e a n y changes in s h a p e o f the b a s a l a r a n d alveolar processes o f the maxillae. I n order to d e t e r m i n e g r o u p effect, the maxillae were subdivided into 3 groups. G r o u p 1 were dentate, groups 2 a n d 3 were e d e n t u l o u s w i t h m o d e r a t e a n d severe r e s o r p t i o n respectively. Results In general, the m e a n values o f the maxillary alveolar m e a s u r e m e n t s are significantly different between groups; the m e a n values o f basal m e a s u r e m e n t s are n o t (Tables 3 A - D ) .

Group 1 2 3

Posterior GP-C mean SD 12.40+_0.89 10.46+_2.96 6.46+_2.54

GP-GP mean SD 30.60+_ 1.82 32.46+_2.37 33.18___1.94

Table 3B. Horizontal maxillary alveolar measurements (mm) (n = 30) Group mean 1 2 3 IC SD 10.00+2.65 6.46_+ 1.66 3.36 +_1.75 I-B mean SD 10.00_+2.00 7.15 +_1.52 3.91 +_1.81 GP-C mean SD 9.20_+ 1.64 6.92 +_1.38 4.73 -t- 1.10 GP-B mean SD 13.80+_2.59 10.69 -t-2.25 8.27 ___1.85

Table 3C. Vertical maxillary basalar measurements (mm) (n = 30) Group Anterior N-ANS ANS-I mean SD mean SD 49.80-+3.27 51.23+_3.24 50.01 +_2.10 13.20_ 1.30 13.15+ 1.52 11.36 +_2.46 Posterior PNS-S mean SD 25.80+0.84 25.92+_ 1.89 25.36 -t- 1.29

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Fig. 4. Maxillary measurements (see Table 2). Vertical (A); horizontal (B); anterior (C); posterior (D).

A classification of the edentulous.jaws

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ANTERIOR
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235

Classification of the edentulous jaws MANDIBLE

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LABIAL

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Since changes in dimension of the basalar process were not significant, regardless of the degree of atrophy of the alveolar process, it was possible to produce composite diagrams showing the most commonly observed changes in shape of the alveolar process of the mandible (Figs. 5A, B) and the maxilla (Figs. 6A, B) and to develop a descriptive classification of these changes. Class I - dentate. Class II - i m m e d i a t e l y post extraction. Class I I I - well-rounded ridge form, adequate in height and width. Class IV - knife-edge ridge form, adequate in height and inadequate in width. Class V flat ridge form, inadequate in height and width. Class VI - depressed ridge form, with some basalar loss evident.

15

II

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Conclusions

Fig. 5. (A) Classification of anterior mandible (anterior to mental foramina). (B) Classification of posterior mandible (posterior to mental foramina).

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Arising from these morphological studies of edentulous jaws, the following conclusions have been drawn. (i) Basal bone does not change shape significantly, unless subjected to harmful local effects such as the overloading of ill fitting dentures. (ii) Alveolar bone changes shape significantly in both the horizontal and vertical axes. (iii) In general, changes of shape of the alveolar bone follows a predictable pattern. (iv) Pattern of bone loss varies with sites. Anterior mandible - bone loss is vertical and horizontal (from the labial aspect). Posterior mandible - bone loss is mainly vertical. Anterior maxilla bone loss is both vertical and horizontal (from the labial aspect). Posterior maxilla - bone loss is both vertical and horizontal (from the buccal aspect). (v) Stage of bone loss can vary anteriorly and posteriorly and between
jaws.

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Fig. 6. (A) Classification of anterior maxilla (B). Classification of posterior maxilla.

236

Cawood & Howell

t r e a t m e n t m e t h o d s ; help in deciding on interceptive techniques to preserve the alveolar process. A n awareness o f the p a t t e r n o f resorption that takes place in the various parts o f the e d e n t u l o u s jaw enables clinicians to anticipate a n d avert future problems.

Such a classification serves to simplify description o f the residual ridge and thereby assist c o m m u n i c a t i o n between clinicians: aid selection o f the app r o p r i a t e s u r g i c a l / p r o s t h o d o n t i c technique; offer an objective baseline f r o m which to evaluate and c o m p a r e different

Acknowledgements The authors acknowledge the valuable assistance of Mr. C. West, Medical Biostatician, University of Liverpool, Mr. R F. Wragg, Senior Registrar in Restorative Dentistry, Glasgow Dental Hospital and Miss S. L. Maudsley, Medical Secretary. References

Table 1A. Vertical mandibular alveolar measurements (mm) (n =45)

S Group I 2 3 4 mean SD 17.50+ 1.44 10.00_+ 1.76 9.21 __+0.94 3.40+ 1.58 M mean SD 16,92_+ 1.11 10.75+ i.36 7.21 _ _ _ 0.73 2.80__ 1.21 K mean SD 7,00+ 1.03 4.00+ 1.26 0.50__+0.67 -- 1.60+ 1.13

Table lB. Horizontal mandibular alveolar measurements (mm) (n=45)

S Group 1 2 3 4 mean SD 11.33 _ _1.33 _ 7.80__ 1.46 6.29 _ 0.87 3.50+ 1.63 M mean SD 10.83 _ _ _ 0.70 5.20_+0.85 4.86 _ 0.46 3.00_+0.76 K mean SD 11.67 + 0.60 4.50+0.74 4.64 0.39 3.80_+0.66

Table 2. Maxillary alveolar and basalar measurements

Site Vertical alveolar basal N ANS I C B I-C ANS-I N-ANS = nasion. =anterior nasal spine. = incisive foramen. =crest of alveolar process (adjacent to I or GP). = widest part of alveolar process (adjacent to I or GP). Anterior Horizontal I-C I-B I-GP GP PNS S Vertical GP-C PNS-S Posterior Horizontal GP-C GP-B GP-GP

1. Atwood, D. A.: Postextraction changes in the adult mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J. Prosthet. Dent. 1963: 13: 810-824. 2. Branemark, E I., Zarb, G. & Albrektsson, T. (eds.): Tissue-integrated prostheses. Osseointegration in clinical dentistry. Berlin: Quintessence, 1985. 3. Enlow, D. H., Bianco, H. J. & Eklund, S.: The remodeling of the edentulous mandible. J. Prosthet. Dent. 1976: 36: 685-693. 4. Kent, J. N., Quinn, J. H., Zide, M. E, Guerra, I. R. & Boyne, E J.: Alveolar ridge augmentation using non-resorbable hydroxylapatite with or without autogenous cancellous bone. J. Oral Max-fae. Surg. 1983: 41: 629-642. 5. Mercier, E & Lafontant, R.: Residual alveolar ridge atrophy: classification and influence of facial morphology. J. Prosthet. Dent. 1979: 41: 90-100. Address: J. L Cawood Maxillofacial Unit Royal Infirmary Chester, CH1 2AZ UK

= greater palatine foramen. =posterior nasal spine. =tunction of vomer with body of sphenoid bone. N-ANS= anterior nasal height. S-PNS =posterior nasal height.