CLASSICAL ARTICLE
Some clinical factors related to rate of resorption of residual ridges
Douglas Allen Atwood, AB, MD, DMD
Boston, Mass.
R esorption of residual ridges is a complex bio-
physical process. Sometimes a simile is made between
bone and ice. If a measured weight is placed on a mea-
sured piece of ice for a given length of time at a given
temperature and atmospheric pressure, a predictable
degree of melting of the ice occurs. This is a physical
process subject to certain physical laws. However, if a
measured force is applied on alveolar bone, either
through natural teeth or through a denture, different
effects are observed in different patients. The force in
this second situation is subject to the same physical
laws, but in addition, the response of the bone is gov-
erned by certain physiologic laws.
Bone resorption of residual ridges is a common
occurrence after the extraction of teeth. In a study pre-
viously reported,1 vertical resorption of the anterior
residual ridges was measurable in 30 or 32 patients
studied cephalometrically after the extraction of
remaining teeth. Both the total amount of bone loss
and the rate of resorption varied among different
patients. In addition, the rate of resorption varied for
a given patient at different times.
In seeking the causes of such variations, it is helpful
if the clinical factors are organized into four major cat-
egories: (1) Anatomic: How much and what kind of
bone does the dentist have to work with? (2)
Metabolic: What is the physiologic capability of this
bone to respond to treatment? (3) Functional: What
functional forces will be placed on this bone? (4)
Prosthetic: What technical details are incorporated
into the prosthesis?
In discussing these various factors,1 I will refer to
18 complete denture patients studied cephalometrical-
ly after the extraction of remaining teeth. These
patients will be used to illustrate basic principles. No
attempt is made or should be made to use this mater-
ial for proof of theories, because the number of
patients is too small for statistical significance.
ANATOMIC FACTORS
Amount of Bone.—Clinically, when examining resid-
ual ridges, the dentist asks: Are the ridges high or low,
broad or narrow, rounded or spiny, or are they covered
Read before the American Prosthodontic Society in Philadelphia, Pa.
Reprinted with permission from J Prosthet Dent 1962;441-50.
doi:10.1067/mpr.2001.117609
AUGUST 2001
by thick or thin mucoperiosteum? Have there been any
recent extractions?
Tracings of cephalometric roentgenograms of the
18 complete denture patients showed considerable
variation in shape and size of the residual ridges
(Fig. 1). However, all patients had reasonably favor-
able ridges at the beginning of the study. Tracings of
2 (patients 59 and 118) show that, if everything else
is equal, there is a potential for more bone loss in
patient 59 than in patient 118—simply because there
is more bone available to be lost. In other words,
clinical joy over big ridges must be tempered with
the sober realization of the greater potential bone
loss over the years of future edentulousness.
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.—Clinically, intraoral roentgenograms
are made to check the density of the residual ridges. In
evaluating such roentgenograms, a three dimensional
object is portrayed on two dimensional film. Two
roentgenograms of apparently equal density may represent
either a wide, poorly calcified bone, a narrow, highly calci-
fied bone, or even different roentgenographic techniques.
Therefore, meaningful evaluation of roentgenograms for
bone density requires a specialized technique with rigid
controls over equipment and development, as well as con-
sideration of the thickness of the soft and hard tissues
examined.
McLean and Urist2 state that a loss of 24 to 30 per
cent of the bone salt is necessary to produce an appre-
ciable change in roentgenograms of bone. In fact, the
diagnosis of osteoporosis3-5 is made more on the basis
of gross pathologic changes in the spine than on crite-
ria of decreased radiodensity of bone. Moreover, the
value of a given treatment of osteoporosis4-6 is based
more on the decrease in symptoms and the cessation of
the progressive decrease in body height than on any
increase in radiodensity of bone. In other words, many
dental patients may have a degree of generalized
osteoporosis and no one knows it.
A standardized study of bone density was not done
in the 18 patients studied. In retrospect, probably
none of the patients had frank osteoporosis. On theo-
THE JOURNAL OF PROSTHETIC DENTISTRY 119
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1.—Tracings of cephalometric roentgenograms of 18 patients reveal (1) considerable vari-
ation in the shape and size of the jaws and (2) different degrees of resorption of the residual
ridges for varying times. Measurements were made as described previously.1
retic grounds, with everything else equal, 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 else” is never equal.
Every patient is different, especially in regard to the
metabolic factors. Any anatomic advantages may be
completely offset by certain metabolic disadvantages.
METABOLIC FACTORS
The concept of differences in the ability of patients
to maintain good bone structure despite unfavorable
factors has been discussed under different names.
Tench7 spoke of bone resistance, Glickman8 of bone
factor, and Applegate9 of bone stability and bone tol-
erance. These terms are used to include a multiplicity
of metabolic factors, metabolism of calcium and phos-
phorus, metabolism of protein, hormonal influences,
inherent potential of the individual, and so on.
General body metabolism is the net sum of all the
building up (anabolism) and the tearing down (catab-
olism) going on in the body. In general terms,
anabolism exceeds catabolism during growth and con-
valescence, levels off during most of adult life, and is
exceeded by catabolism during disease and senescence.
Bone has its own specific metabolism and undergoes
equivalent changes. At no time during life is bone sta-
120
ATWOOD
tic, but rather it is constantly rebuilding, resorbing,
and remodeling, subject to functional and metabolic
stresses.
The four main levels of bone activity are (1) equi-
librium, (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 hyperparathy-
roidism and in pressure resorption. Both sides of the
equilibrium must be known to understand bone
metabolism. The relative activity of both the
osteoblasts and the osteoclasts must be known. In
equilibrium, the two antagonistic actions are in bal-
ance. In growth, although resorption is constantly
taking place in the remodeling of the bones as they
grow, increased osteblastic activity more than makes
up for the bone destruction. In osteoporosis,
osteoblasts are hypoactive,2,3 whereas in the resorption
of hyperparathyroidism, increased osteoblastic activity
is unable to keep up with the increased osteoclastic
activity.2,10 The normal equilibrium may be upset and
pathologic bone loss may occur if either bone resorp-
tion is increased or bone formation is decreased, or if
both occur (Fig. 2).8
Since bone metabolism is dependent on cell metab-
olism, anything that influences cell metabolism and,
VOLUME 86 NUMBER 2
ATWOOD THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2—A, The diagrammatic representation of the physiologic equilibrium responsible for the
maintenance of the height of alveolar bone. B, Bone loss as the result of an imbalance creat-
ed by increased resorption. C, Bone loss as the result of a diminution in normal formation. D,
Bone loss as the result of increased resorption and diminished formation. (From Glickman, I.:
Clinical Periodontology, ed 2, Philadelphia and London, 1958, W. B. Saunders Company.)

specifically, the metabolism of osteoblasts and osteo-
clasts is important. Several examples may be given. The
thyroid hormone affects the rate of metabolism of cells
in general2 and hence the activity of both the
osteoblasts and osteoclasts. Parathyroid hormone
influences the excretion of phosphorus in the kidney
and also directly influences osteoclasts.2,8,11,12 The
degree of absorption of calcium, phosphorus, and pro-
teins11 determines the amount of building blocks
available for the growth and maintenance of bone.
Vitamin C aids in bone matrix formation.2 Vitamin D
acts through its influence on the rate of absorption of
calcium in the intestines and on the citric acid content
of bone.2 Various members of the vitamin B complex
are essential for normal cell metabolism, including
bone cells.11 Much is known about these and many
other metabolic factors.2,5,10-13 However, much
remains to be learned, especially in the practical appli-
cation of this knowledge.
One of the most interesting metabolic phenomena
concerns the antagonistic effects of the “anabolic hor-
mones” (estrogen and testosterone) and the
“antianabolic hormones” (the adrenal glucocorticoid
hormones, including cortisone and hydrocortisone).
According to Reifenstein,3,5 in the young person,
there is a relative predominance of the anabolic hor-
mones, resulting in continued growth and maturation
of the skeleton (Fig. 3). At some point in the normal
young adult, the anabolic and antianabolic hormones
are in balance, with the result that bone formation and
bone resorption are in equilibrium, and bone mass
remains constant. Reifenstein3,5 states that as all peo-
ple get older, especially women past the menopause,
the anabolic hormones are so reduced that the antian-
abolic 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 (Fig. 4).
Although he believes this imbalance occurs in all aging
people as a general, nonspecific influence predisposing
to senile osteoporosis, he postulates the existence of
another factor (or factors) in the bone itself which
accounts for the fact that not all aging people get
osteoporosis. Henneman and Wallach4 report the
treatment of approximately 200 postmenopausal

AUGUST 2001 121

THE JOURNAL OF PROSTHETIC DENTISTRY ATWOOD

Fig. 3.—A diagrammatic representation of the relative activity of the anabolic steroids (estro-
gen and androgen) and the antianabolic steroids (the glucocorticoid steroids, shown as
neutral reducing lipids). As both men and women grow older, the anabolic steroids decrease
more rapidly than the antianabolic steroids, giving a relative predominance of the antiana-
bolic hormones. (From Reifenstein, E. C., Jr.: Clin. Orthop. 10:206-253, 1957, published by
the J. B. Lippincott Company.)

women in whom progression of osteoporosis was
arrested in nearly all instances. Although estrogen
apparently arrested the disease, the bone was not
rebuilt in a single subject.
One of the more interesting and potentially fruitful
forms of research is tissue culture in which both
osteoblasts and osteoclasts can be studied microscopi-
cally and chemically in the living state.13
Research in periodontal disease is not unrelated to
prosthetic problems, because both are concerned with
the differences in “bone factor” between different
individuals. In this regard, it is interesting, although
not statistically significant, to observe the periodontal
background of the 18 patients. Of the 11 patients who
had significant bone loss, 8 (73 per cent) had moder-
ate or advanced periodontal disease, whereas 3 of 7
(43 percent) without significant bone loss had
advanced periodontal disease. Perhaps even more
interesting are the negative findings. Significant ridge
resorption occurred in 3 patients who had had no peri-
odontal disease, and a lack of ridge resorption
occurred in the 3 patients who had had at least mod-
erate periodontal disease.
Metabolic differences are undoubtedly most signif-
icant in the response of a given individual to a given
stress and account for the variations among individuals
and within the same individual at different times.
Unfortunately, it is not easy to delineate these meta-
bolic factors clinically because of the tremendous
number of variables, the difficulty in measuring some
of the variables, and the complexity of their interrela-
tionships. Even variables that are easy to measure such
as age and sex, fail to give much information, for
chronologic age fails to give an accurate measure of
metabolic age, and mere knowledge of sex fails to give
the relative activity of the male and female hormones
which occur in both men and women.
For example, among the 18 patients, the average
age for those with significant bone loss was 47 years,
whereas the average age for those without significant
bone loss was 34 years. This difference suggests an age
factor as in the theory of Reifenstein2,5 for osteoporo-
sis, but we are cautioned against oversimplification by
the significant overlapping of the ages of the two
groups, some young and some old in each group.
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 judgment,
which is notoriously poor. We evaluate the general
nutrition, metabolism, and hormonal activity of the
patient. Sometimes age or sex provides clues. A dental

122 VOLUME 86 NUMBER 2

ATWOOD
history of or clinical evidence of inordinate previous
bone loss may suggest a poor bone factor, but such
bone loss must be evaluated in light of the anatomic,
functional, and prosthetic factors. Roentgenologic or
other evidence of osteoporosis may indicate an unfa-
vorable metabolic environment for the prosthesis. Too
often, we must use hindsight in establishing the diag-
nosis.
FUNCTIONAL FACTORS
When force within certain physiologic limits is
applied to living bone, that force, whether compres-
sive, 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, inten-
sity, duration, and direction of force are somehow
translated into biologic cell activity. Inasmuch as the
end result is brought about by cell activity, the meta-
bolic factors are important. However, in that cell
activity is influenced by force, the functional factors are
also important. Evans14 stresses that mechanical fac-
tors constitute just one of several types of factors that
operate in the development and maintenance of the
normal form and size of bone. Henneman and
Wallach4 consider 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 periodon-
tal 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 tra-
A B
Fig. 4.—Schematic diagrams illustrate the relationship of steroid hormones to the develop-
ment and treatment of senile osteoporosis. (From Reifenstein, E. C., Jr.: Clin, Orthop.
10:206-253, 1957, published by the J. B. Lippincott Company.)
AUGUST 2001
THE JOURNAL OF PROSTHETIC DENTISTRY
becular structure conforms in pattern to these trajec-
tories.10,15,16 Evans14 discusses both sides of this
theory.
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 patients as compared with dentulous patients that
the trabeculae were 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 small-
er. Neufeld15 also found that instead of the usual
trajectories present in the dentulous mandible, the tra-
becular pattern in the edentulous mandible was, in
general, random, except that in some specimens the
trabeculae near the crest of the ridge were somewhat
perpendicular, suggesting the development of trajecto-
ries to the compressive force of a denture.
When are the functional factors of frequency, inten-
sity, 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 for-
mation could well be trauma to another patient,
resulting in bone resorption. The functional factors
must be interpreted in conjunction with the metabol-
ic and anatomic factors.
Disuse atrophy and fracture are examples of
extremes of functional forces. On the one hand, frac-
tures can occur either from a single sudden force of a
magnitude beyond the breaking point, as in a single
hard blow to the skull, or they can occur because of a
force below breaking power which is applied many
times, as in the “march fracture”17 of the metatarsal
bones seen among footsoldiers. On the other hand,
C
123
THE JOURNAL OF PROSTHETIC DENTISTRY
disuse atrophy may be generalized, as seen in a chron-
ic bedpatient, or localized, as in the alveolar bone
around an unused, unopposed molar tooth.10
Clinically, functional factors are very hard to mea-
sure in a meaningful way. In a given patient, the
intensity of muscular power as measured by a gnatho-
dynamometer may be great, but the frequency,
duration, and direction of the force applied to the
bone may be well within the tolerance of the bone to
absorb this force. On the other hand, a patient may
have muscles of only average power, but have perni-
cious habits of clenching, thereby increasing the
frequency and duration of force or of grinding and
thereby applying the force in a more traumatic direc-
tion. Bruxism has long been recognized as a
pathologic function leading to overstimulation of the
stomatognathic system, with breakdown occurring in
the weakest link, usually as attrition of the teeth or
periodontoclasia. Of the patients with significant ridge
resorption, 73 per cent had either moderate to marked
attrition of the natural teeth prior to extraction or a
history of bruxism or both, while only 29 per cent
without significant ridge resorption had a similar back-
ground. These figures are not statistically significant
because of the small group, but they are interesting to
clinicians and suggest avenues for further study.
Similarly, 36 per cent of the patients who had signifi-
cant bone resorption after the insertion of dentures
did not have an adequate interocclusal distance, i.e., 1
mm. or more, during that period, whereas only 14 per
cent of those without significant bone resorption had
this situation. If there is not sufficient interocclusal dis-
tance, the frequency and duration of force on the
residual ridges may be increased to a pathologic degree
depending on the complex interrelationship with the
anatomic and metabolic factors. The exceptions in
either direction make interesting study.
PROSTHETIC FACTORS
Ridge resorption may or may not occur in patients
for whom dentures are not made. If resorption does
occur, it is attributed either to disuse atrophy or, as
Lammie18 suggests, to an atrophying mucosa seeking
a reduced area, thereby causing pressure resorption of
the ridge. If resorption does not occur, this is attrib-
uted either to function by a patient who is able to
“gum” food because of a small interridge space or
unknown factors.
The prosthetic factors are extremely difficult to
evaluate because of the tremendous number of vari-
ables, including the anatomic, metabolic, and
functional factors. Often, a new technique, a new
impression material, a new denture base, or a new
tooth has been heralded as the answer to the problem
of ridge resorption. Often our hopes are dashed to the
ground by failure. Many times we blame ourselves for
124
ATWOOD
this failure, when in reality the promises of success
could not possibly be guaranteed because the tech-
nique or material had no control over certain
imponderable factors.
This does not mean that technique is not important
or significant, that bad prosthetic techniques will not
make problem patients more difficult, or that good
prosthetic techniques will not get better results on the
average than poor prosthetic techniques. It only means
that the knowledge of and the control of all the factors
involved in ridge resorption are so imperfect that
resorption may occur despite our best efforts and that
resorption may not occur despite the gaps in our
knowledge.
It would be a tremendous undertaking to gather
sufficient information about enough patients over an
adequate period of time to be able to sort out some of
the variables such as functional wax closed mouth
impressions versus mucostatic zinc oxide–eugenol
open mouth impressions, porcelain teeth versus acrylic
resin teeth, cusped teeth versus flat teeth, wide teeth
versus narrow teeth, a full complement of teeth versus
less than a full complement, “over the ridge” arrange-
ment versus natural placement, a flat plane versus a
curved plane, balance in all positions versus balance in
centric position only, most retruded versus “function-
al” centric relation, etc.
In the small study described, the prosthetic factors
may be summarized as follows: In each group (those
with and those without significant bone loss), some
dentures were made with closed mouth impressions,
some with open mouth impressions, some with zero
degree acrylic resin teeth, some with French’s porcelain
teeth, some with a flat occlusal plane, some with a
Monson curve, some with needle point tracings, some
with wax interocclusal records, some with second
molars and some without, and some at the Harvard
School of Dental Medicine and some at the Veterans
Administration Hospital. There were no prosthetic fac-
tors which were exclusively favorable or unfavorable.
The findings, although not statistically significant,
suggest that clinical judgment in prosthodontics
depends not only on a profound understanding of the
myriad of significant technical factors but also on the
understanding of complex interrelationships of these
technical factors with the anatomic, metabolic, and
functional factors. This is what makes prosthodontics
challenging. This is what makes prosthodontics fun.
SUMMARY
Bone resorption of residual ridges is common. The
rate of resorption varies among different individuals
and within the same individual at different times.
Factors related to the rate of resorption are divided
into anatomic, metabolic, functional, and prosthetic
factors.
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ATWOOD THE JOURNAL OF PROSTHETIC DENTISTRY

Anatomic factors include the size, shape, and densi-
ty of ridges, the thickness and character of the mucosa
covering, the ridge relationships, and the number and
depth of sockets.
Metabolic factors include all of the multiple nutri-
tional, hormonal, and other metabolic factors which
influence the relative cellular activity of the bone-
forming cells (osteoblasts) and the bone-resorbing
cells (osteoclasts). Age, sex, and general health are
inadequate to describe the bone factor but do give
some clinical clues.
Functional factors include the frequency, intensity,
duration, and direction of forces applied to bone
which are translated into cellular activity, resulting in
either bone formation or bone resorption, depending
on the patient’s individual resistance to these forces.
Prosthetic factors include the myriad of techniques,
materials, concepts, principles, and practices which are
incorporated into the prostheses.
Although the various factors can be divided into
these four groups for academic purposes, they are all
interrelated, and any one factor may be evaluated only
if we place it in its proper perspective to all factors.
Since bone resorption depends on the response of
living cells to force, the more basic sciences concerned
with the physiology and pathology of cells are under-
stood, the more educated will be our clinical
judgment.
REFERENCES
1. Atwood, D. A.: A Cephalometric Study of the Clinical Rest Position of the
Mandible. II. The Variability in the Rate of Bone Loss Following the
Removal of Occlusal Contacts, J. Pros. Den. 7:544-552, 1957.
2. McLean, F. C., and Urist, M. R.: Bone, an Introduction to the Physiology
of Skeletal Tissue, ed, 2, Chicago, 1961, University of Chicago Press.
3. Rodahl, K., Nicholson, J. T., and Brown, E. M., editors: Bone as a Tissue,
New York, 1960, Blakiston Company.
4. Henneman, P. H., and Wallach, S.: A Review of the Prolonged Use of
Estrogens and Androgens in Postmenopausal and Senile Osteoporosis,
A.M.A. Arch. Int. Med. 100:715-723, 1957.
5. Reifenstein, E. C., Jr.: The Relationship of Steroid Hormones to the
Development and Management of Osteoporosis in Aging People, Clin.
Orthop. 10:206-253, 1957.
6. Moldawer, M.: Senile Osteoporosis: Physiologic Basis of Treatment,
A.M.A. Arch. Int. Med. 96:202-214, 1955.
7. Tench, R. W.: Dangers in Dental Reconstruction Involving Increase of the
Vertical Dimension of the Lower Third of the Human Face, J.A.D.A. and
D. Cosmos. 25:566-570, 1938.
8. Glickman, I.: Clinical Periodontology, ed. 2, Philadelphia and London,
1958, W. B. Saunders Company.
9. Applegate, O. C.: Essentials of Removable Partial Denture Prosthesis,
Philadelphia and London, 1954, W. B. Saunders Company.
10. Weinmann, J. P., and Sicher, H.: Bone and Bones. Fundamentals of Bone
Biology, ed. 2, St. Louis. 1955, The C. V. Mosby Company.
11. Irving, J. T.: Calcium Metabolism, New York, 1957, John Wiley & Sons,
Inc.
12. Greep, R. O., and Talmage, R. V., editors: The Parathyroids, Springfield,
Ill., 1961, Charles C Thomas, Publisher.
13. Goldhaber, P.: Behaviour of Bone in Tissue Culture, in Sognnaes, R. F.,
editor: Calcification in Biological Systems, Washington D. C., 1960,
American Association for the Advancement of Science.
14. Evans, F. G.: Stress and Strain in Bones. Their Relation to Fractures and
Osteogenesis, Springfield, Ill., 1957, Charles C Thomas, Publisher.
15. Neufeld, J. O.: Changes in the Trabecular Pattern of the Mandible
Following the Loss of Teeth, J. Pros. Den. 8:685-697,1958.
16. Sicher, H.: Oral Anatomy, ed. 2, St. Louis, 1952, The C. V. Mosby
Company.
17. Sante, L. R.: Principles of Roentgenological Interpretation, ed. 11, Ann
Arbor, Mich., 1958, Edwards Bros., Inc.
18. Lammie, G. A.: Aging Changes and the Complete Lower Denture, J. Pros.
Den. 6:450-464, 1956.
29 COMMONWEALTH AVE.
BOSTON, MASS.

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