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ALVEOLAR BONE

ITS RELEVANCE IN PROSTHODONTICS

CONTENT Topic Introduction Systemic influences on alveolar bone Effects of hormones Effects of vitamins Effects of drugs Prosthodontic considerations of alveolar bone in relation to Complete denture Single complete denture Removable partial denture Fixed partial denture. Implants. Combination syndrome Conclusion References Page no. 3-6 7 8-9 10 10

12 12 13 14 15 16-18 19 20-21

Introduction

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According to Glossary of prosthodontics alveolar bone is defined as bony portion of mandible or maxilla in which roots of teeth are held by fibers of periodontal ligament. A.R Tencate states that alveolar bone is that portion of maxilla and mandible which forms & supports roots of teeth. It forms when tooth erupts, to provide the osseous attachment to the forming periodontal ligament and disappears gradually after tooth is lost. It is extremely important to the dental practitioner, as almost all his treatment procedures can be successful only if the bony support remains intact. The success of complete denture, partial dentures, implants is dependent on degree of stability that the underlying bone can maintain.

Residual Ridge Resorption


Alveolar bone has one of the highest metabolic rate, owing to nearly continous masticatory stress applied to it through tensile forces transmitted throught periodontal ligament. Residual Ridge Resorption is chronic, progressive, irreversible, cumulative, multifactorial, biomechanical disease that results from a combination of anatomic, metabolic and mechanical determinants. After teeth loss, alveolar bone undergoes rapid remodeling. Which results in bone loss. Amount of bone loss varies among individuals and depends on - Age - Sex - Nutritional status - Medical conditions - Original shape - Size and location of alveolar process

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Factors affecting rate at which bone is lost Anatomical size of ridge following extraction - type of residual bone - type of mucoperiosteum - Location with in oralcavity Metabolic - Age -Sex -diet -harmonal status Functional - Frequency, direction and amount of force applied to ridge. Prosthetic factor - type of denture base, - forms and type of teeth, - interocclusal distance. Osteoclasts have the function of eliminating bone i.e. no longer adapted to mechanical forces. At the site of bone formation, osteoblasts differentiate from precursor cells of connective tissue. The mechanisms which determine bone formation at any given site are unknown. They must be varied and determined on a genetic and functional basis. Osteoblasts form osteoid tissue which will be followed by mineralization. It always lags behind production of bone matrix and therefore in such areas a superficial layer of osteoid tissue is always seen. A peptide called osteoclastic activating factor is found in lymphocytes and is capable of increasing AMP and osteoclastic activity and reducing osteoblastic activity at target site. The exact mechanism by which osteoclasts may act to resorb the bone is not clear. The osteoclasts may liberate enzymes which dissolve the organic matrix and remaining inorganic salts. May then be dissolved by

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chelating agents such as EDTA, C.AMP in cells may play some role in bone resorption. The initiation of resorption is not completely known. It may be due to dying or dead osteocytes that stimulate the connective tissue, resulting in osteoclasts in the area. Thomas, Stahl and Pendleton consider alveolar ridge resorption as normal biologic process that increases with age. Bones have an intrinsic growth pattern as stated by TOWNSLEY in 1948 and it is possible that the alveolar bone may have a hereditary resorption pattern.
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In 1971, Atewood described RRR as MAJOR ORAL DISEASE ENTITY characterised by loss of oral bone after the extraction of teeth.

- The size, shape and tolerance of residual ridges provides the basis of stability, retention, support of complete denture.
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New Feld reported In some of specimens studied, the trabecular pattern was arranged in a such a way that it indicated that there was some adaptation of structure of bones to presence of an appliance in region near the superior surface of alveolar process.

- Atewood reported A complete abscence of periosteal bone over residual ridge in all specimens studied.
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Clayton. F. Parkinson in 1978 stated that

i) Arch width of maxilla is

less than mandible in molar region by 6 - 7 mm ii) Alveolar resorption rate is highest in early stages of edentulism and slows with loss of bone, longevity of edentulism and the attendant wearing dentures.
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Antje. Tallgren in 1972 stated that mean reduction in lower anterior ridge height is approximately four times as great as that of upper ridge. Tallgren stated that RRR 1 damping effect of the mucosa
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Winkler observed that RRR Anatomical factors Time

Bone resorption factors Bone formation factors

Force factors Damping Effect

According to Atwood D.A. Class I Pre extraction Class II Post extraction. Immediately following exfoliaition of tooth with, the labial and lingual alveolar process remaining Class III High well rounded. The sharp edges will be rounded OFF by the external osteoclastic activities leaving a high well rounded residual ridge. Class IV Knife edge. As resorption continues form both labial and lingual aspects the crest of ridge becomes increasingly narrow finally results in knife edge. Class V Low well rounded. The knife edge shortens and finally leaving low well rounded or flat ridge. Class VI Depressed. Further resorption leaving only the thin cortical bone in lower border of body of maxilla

Age changes
Age changes in alveolar bone are similar to those occurring in remainder of skeletal system. These include osteoporosis
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- decreased vascularity - reduction in metabolic rate - reduction in healing capacity - Bone resorption may be increased or decreased and the density of alveolar bone may increase or decrease depending on its location. There is greater irregularity in surfaces of alveolar bone facing the PDL with advancing age. - Older persons is likely to have more alveolar ridge resorption than a younger person. - In aged, resorption is not compensated by production of bone, resulting in senile osteoporosis. In persons over 70 yrs of age, 25% of bone may be engaged in bone resorption. REIFENSTEIN in 1950 stated that osteoporosis may be normal after menopause. osteoporosis. Influence of systemic diseases 1. Protein deficiency causes loss of alveolar bone which is the result of inhibition of normal bone forming activity.
2.

Alveolar ridge may show resorption in connection with

Acute starvation results in osteoporosis and reduction in height of alveolar bone.

3. In hyperpitutarism (acromegaly) marked over growth of alveolar bone causes increase in size of dental arch. 4. Ridge resorption is associated with hyperparathyroidism and vonrecklinghausens disease due to increased bone loss. a. Radiological findings of hyperparathyroidism are alveolar osteoporosis with closely meshed trabeculae, widening of PDL space and loss of laminadura.
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5. Complete loss of laminadura occurs in pagets disease, Fibrous dysplasia, osteomalasia. 6. Diabetes mellitus shows rapid alveolar bone loss. 7. In acute, sub acute leukemia, marrow of alveolar bone exhibits localized areas of necrosis, thrombosis of blood vessels, leukocytic infiltration and replacement of fatty marrow with fibrous tissue. 8. In agranulocytosis, osteoporosis of alveolar bone with osteoclastic resorption, necrosis of alveolar bone and heamorrhage in the marrow occur. 9. Mercury intoxification leads to destruction of alveolar bone. 10. Other chemicals such as phosphorous, arsenic and chromium may cause necrosis of alveolar bone. 11. Benzene intoxification also leads to destruction of alveolar bone. 12. Hypophoshatasia, an inherited disease causes premature loss of alveolar bone surrounding decidous incisors by 10 months of age.

Effect of hormones Hormones such as androgens, estrogens and somatotropin exert a definite influence on growing alveolar bone, but their effect on adult bone is not clear. - PTH has direct action on adult bone, which is responsible for maintainence of normal blood calcium levels of 10-11 mg% - PTH has 4 main sites of activity namely 1) kidney 2) bone 3) intestine 4) lactating mammary gland. - PTH is probably the most important of harmones in so far as RRR is concerned. - In alveolar bone PTH liberates both calcium and phosphate. When PTH is active, calcium and phosphate ions move from alveolar bone to
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plasma. But it is not known whether PTH acts directly or through osteoclasts. - When circulating PTH is high, it leads to osteoporosis which in turn leads to resorption of alveolar ridge. A decrease in PTH level results in increase formation of bone hence resorption of alveolar bone is reduced. Calcitonin It has antagonist action compared to PTH. Estrogen : Estrogen deficiency causes increased bone resorption activity where as surface of residual ridge alveolar bone in oestrogen deficiency and its replacement therapy seem to affect the activity of residual ridge bone remodelling at the molecular level. Osteoporosis is predominant side effect of menopause which is due to decrease of oestrogen production. Although the osteoporotic change of maxilla mandible occur elderly patients in a fashion similar to that of metacarpal bone and vertebral bone. NISHIMURA et al. reported that, although bone height showed no differences, the knife edge morphologic features of mandibular residual ridge was statistically associated with osteoporotic changes in 2nd vertebrate bone.

Effects of vitamins on alveolar bone :


1. Hypervitaminosis D- causes generalized resorption changes in bone including alveolar bone. 2. Avitaminosis D causes decreased concentration of blood phosphate and retarded calcification.

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3. Chronic hypervitaminosis A- WEINMANN & SICHER in 1955 noted that above condition leads to bone resorption in supporting bone of the alveolar process in those regions most subject to stress. 4. Hypovitaminosis A- leads to overall bone growth retardation and in later stages endochondral bone growth ceases entirely. 5. Hypovitaminosis C leads to SCURVY. It causes failure of collagen production in bone. Production of osteoid is deficient and hence calcification is restricted. However, bone resorption continues and eventually bone becomes thin and fragile, which is prone for fracture. It is characterized by decreased activity of fibroblasts, osteoblasts, odontoblasts, which ultimately effects collagen production.

EFFECT OF DRUGS A generalised decrease in alveolar bone mass is associated with chronic corticosteroid therapy, anticonvulsant therapy, long term high dose heparin therapy and alcoholism.

PROSTHODONTIC CONSIDERATIONS OF ALVEOLAR BONE : In relation to complete denture : Alveolar bone is the basic support for the complete dentures. It provides most of the vertical support. After loss of teeth, re-constructive process leads generally to loss of bone in the area and the formation of compact lamellae at surface. Histologically, socket is filled with immature bone by the end of 2nd month. But there is some quantitative loss when healing is uneventful; when primary clot fails to form. The denuded bone necrotizes and is elminated by resorption. This loss in quantity during healing after extraction is one of the

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reasons awaiting period of 6 weeks to 2 months is advocated prior to placement of dentures. Another reason is to allow the immature bone to replace the young connective tissue. Continuous presence of dentures is capable of exerting pressure of sufficient intensity to produce resorption. This is true in mandibular arch, since gravity exerts a steady pull on denture. A complete denture is potentially capable of exerting steady pressure that can interrupt the blood supply. For this season the dentures should be removed at least for 8 hours a day. WEINMAN SICHER reported that whether intermittent pressure is tolerated or even beneficial or whether it too leads to loss of bone depends entirely on its affects on blood circulation. Boucher stated that prominent alveolar ridges with parallel buccal and lingual walls may also provide significant retention by increasing surface area between denture and mucosa there by maximizing interfacial and atmospheric forces. Factors that influence the form and size of supporting bone include. 1) Original size and consistency. 2) Persons general health. 3) Forces developed by surrounding musculature. 4) Severity and location of periodontal disease. 5) Surgery at time of extraction. 6) Relative length of time different parts of jaws have been edentulous. K. W. Tyson, J. C. Mcford stated that in case of flat ridges 1. Their should be increased free way space by 2 3 mm 2. Impression should cover as much area as possible

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3. Peripheral form of polished denture should be in hormone with buccinator muscle. Ashman stated that ridge preservation can be done by 1. Advanced extraction therapy (AET) In this after extraction introduction of synthetic graft in to the socket was done followed by suturing. He observed that their was not change in height and width of the bone 2. Replacement therapy An alloplast graft was placed in an extraction socket, or in combination with titanium threaded implant immediately after extraction RESORPTION PATTERN

Single complete dentures : In upper jaw the premaxillary area is frequently subjected to more resorption when the patient is wearing a complete denture which occludes with natural anterior lower teeth. If magnitude of major force of occlusion is great i.e., no partial denture fitted, the alveolar bone will be resorbed in that area, leaving a soft flabby ridge of tender inflamed tissue. Even when free end saddle partial denture, has been fitted, it is inevitable that once any resorption has taken place, the major forces of
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occlusion will again be thrust on the anterior teeth to be dissipated in upper jaw through the premaxillary edentulous ridge. However carefully the complete denture for upper and lower ridges are made with occlusal forces concentrated in posterior region rather than anterior bringing the teeth in to occlusion will often thrust upper denture upward and forward on unstable, tender premaxillary tissues. This is one of the most irrevocable injuries done to mouth by dentures.

Removable partial denture and fixed partial denture : The radiographic interpretation aspects that are the most pertinent to RPD & FPD construction, are those relative to prognosis of remaining teeth used as abutments. i) Quality of support from alveolar bone of an abutment tooth is of primary important because the tooth will have to withstand greater stresses loads when supporting RPD & FPD. Abutment teeth providing total abutment support to RPD & FPD, will have to with stand a greater load than before and especially greater horizontal forces. It is minimized by establishing harmonious occlusion and by distributing horizontal forces among several teeth through the use of rigid connectors. Properly designed tooth borne removable prosthesis should provide bilateral stabilization against horizontal forces. ii) Abutment teeth adjacent to distal extension bases in RPDs are subjected not only to vertical and horizontal forces but to torque also because of tissue supported base. Vertical support and stabilization against horizontal movement with rigid connectors and just as important as they are with a tooth borne prosthesis.

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In addition, abutment tooth adjacent to the extension base will be subjected to torque in proportion to design of retainers, size of denture base, tissue, support by base and total occlusal forces applied. iii) In RPD, if alveolar bone support is adequate a posterior abutment should be retained if at all possible in reference to a tissue supported extension base. iv) In case of RPD & FPD teeth with insufficient alveolar support may be extracted if their prognosis is poor and other adjacent teeth may be used to better advantage as abutments. v) Radiographic interpretation also serve as an important function if used periodically after the placement of RPD and FPD. Further bone changes of any type suggest traumatic interference from some source. Radiographic observations made are 1. Alveolar bone crest resorption 2. Integrity of thickness of laminadura 3. Evidence of generalized horizontal bone loss 4. Evidence of vertical bone loss 5. Widened pdl space 6. Density of trabeculae of both arches 7. Crown and root ratio. Antes law states that for fixed partial dentures the pericemental area of all abutment teeth supporting the FPD should be equal to or greater than the pericemental area of the teeth to be replaced.

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For removable partial dentures it states that combined pericemental area plus mucosal area should be equal to or greater than pericemental area of missing teeth. INDEX AREAS are those of alveolar bone support that disclose the reaction of bone to additional stress. The reaction of bone to additional stress in index areas may be negative or positive. With evidence of a supporting trabecular pattern, a heavy cortical layer and a dense lamina dura, or reverse response with the former, patient is said to have +ve bone factor, meaning ability to build additional support where ever needed. With the later patients is said to have negative bone factor meaning inability to respond favourably to stress. In FPD general alveolar bone levels with particular emphasis on abutment teeth should be observed. Any widening of PDL space and loss of intact of laminadura due to destruction of cribriform plate should always be correlated with occlusal prematurities or occlusal trauma. An evaluation can be made of thickness of cortical plate of alveolar bone around teeth and of the trabeculation of bone. Implants : When we talk of implants in relation to alveolar bone first one should think about OSSEOINTEGRTION. It is defined as direct structural and functional connection between ordered, living bone and the surface of a load carrying implant.

COMBINATION SYNDROME

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Definition: The Glossary of Prosthodontic Terms defines combination syndrome as "the characteristic features that occur when an edentulous maxilla is opposed by natural mandibular anterior teeth, including loss of bone from the anterior portion of the maxillary ridge, overgrowth of the tuberosities, papillary hyperplasia of the hard palatal mucosa, extrusion of mandibular anterior teeth, and loss of alveolar bone and ridge height beneath the mandibular removable partial denture bases, also called anterior hyperfunction syndrome. A few years later, further characteristics were added to the combination syndrome : loss of vertical dimension of occlusion, occlusal plane discrepancy, anterior spatial repositioning of the mandible, poor adaptation of the prosthesis, epulis fissuratum, and periodontal changes. However, these changes are not generally associated with combination syndrome. (Palmquist Sigvard et al) When natural anterior teeth are remaining in the mandible opposing a maxillary edentulous arch results in combination syndrome. These changes are: - (Kelly Elswarth) i) Loss of bone from the anterior part of the maxillary ridge. ii) Overgrowth of tuberosities iii) Papillary hyperplasia in the hard palate. iv) Extrusion of the lower anterior teeth. v) The loss of bone under the partial denture base.

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In spite of his emphasis on the negative role of the Mandibular RPD, Kelly wrote: "The early loss of bone from the anterior part of the maxillary jaw is the key to the other changes of the combination syndrome". Dorland's illustrated Medical Dictionary defines "syndrome" as 'a set of symptoms which occur together; the sum of signs of any morbid state; a symptom complex". "Combination syndrome" is not included among

hundreds of syndromes listed in the dictionary. From this review of the literature it seems obvious that "combination syndrome" does not meet the criteria to be included in such a list.

Prevention of Combination Syndrome: Try to avoid maxillary edentulous arches with mandibular natural teeth situation. Authors do not advocate removal of lower anteriors, but rather to retain the weak posterior teeth as abutments by means of endodontic and periodontic techniques. Endosseous implants, hemi section, root amputation can be done to preserve lower molar.

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An overlay denture on lower may avoid combination syndrome. Surgical excision of flabby (hyperplastic) tissue, papillary hyperplasia and enlarged tuberosities. This allows the distal end of the occlusal plane to be raised to the proper level. (Cynthia P. Thiel et al) Covering maximum area in lower partial denture. Covering retromolar pad where muscle and raphe attachments

prevent or reduce resorption, and covering buccal shelf is necessary to retard bone loss.

conclusion
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Now we all know the importance of alveolar bone in dentistry. But it is well for us to understand the still further physiology of bone. It is especially necessary to remember the factors such as harmones, vitamins, pressure, age which may all or separately produce ridge resorption. Unless until mechanism of bone resorption is understood little progress will be made in prosthodontic therapy. When alveolar bone loss can be controlled, it will be possible to offer the patient dentures with a greatly increased chance of success.

REFERENCES
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1. Winkler Sheldon Essentials of complete denture prosthodontics. 2nd

Edition.
2. Sharry J.J. Complete denture prosthodontics, 3rd edition.

3. Bernard Levin Impressions for complete dentures. 4. Carl E. Mish Contemporary Implant Dentistry, Second Edition. 5. Ortman L.F. et al, 1992. Bioelectric stimulation and residual ridge resorption. J. Prosthet. Dent; 67 : 67-71. 6. Israel Harry 1979. Evidence for continued apposition of adult mandibular bone from skeletalized materials. J. Prosthet. Dent; 41 : 101-104. 7. Atwood D.A., Coy W.A., 1971. Clinical, cephalometric and densitometric study of reduction of residual ridges. J. Prosthet. Dent., 26 : 280-295. 8. Atwood D.A., 1971. Reduction of residual ridges : A major oral disease entity. J. Prosthet. Dent., 26 : 266-279. 9. Mercier Paul, Lafontant Roger, 1979. "Residual alveolar ridge atrophy: Classification and influence of facial morphology". J. Prosthet. Dent., 41: 90-100. 10.Baylink D.J. et al., 1974. Systemic factors in alveolar bone loss. J. Prosthet. Dent., 31 : 486-505. 11.Kelsey C.C., 1971. Alveolar bone resorption under complete denture. J. Prosthet. Dent., 25 : 152-161.

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12.Wical K.E., Swoope C.C., 1974. Studies of residual ridge resorption. Part-II. The relationship of dietary calcium and phosphorus to residual ridge resorption. J. Prosthet. Dent; 32 : 13-22. 13.Sones American Diana et al, 1986. Osteoporosis and mandibular bone resorption : A prosthodontic perspective. J. Prosthet. Dent., 56 : 732736. 14.Atwood Douglas Allen 1958. A cephalometric study of the clinical rest position of the mandible. J. Prosthet. Dent., 8 : 698-708. 15.Palmquist Siguard et al. 2003. The combination syndrome : A literature review. J. Prosthet. Dent; 90 : 270-5. 16.Kelly Ellswarth 1972. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J. Prosthet. Dent., 27 : 140-150. 17.Palmer C.A. 2003. Gerodontic nutrition and dietary counseling for prosthodontic patients. Dent. Clin. N. Am., 47 : 355-371. 18.Wical K.E., Brussee P., 1979. Effect of calcium and vitamin D supplement on alveolar ridge resorption in immediate denture patients. J. Prosthet. Dent; 41 : 4-11.

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