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Residual Ridge

Resorption

Akshay Gupta

Introduction
Definition
Cells of bone
Pathology of residual ridge resorption
Classification
Patho physiology
Pathogenesis
Etiology
Consequences
Management



INTRODUCTION
A major oral disease entity
ATWOOD (1971)

It is chronic progressive
irreversible and disabling
disease probably of
multifactorial origin.
Definition (GPT8)
Residual bone that component of maxilla
or mandible ,once used to support the roots
of the teeth, that remains after the teeth are
lost.
Residual ridge portion of the Residual
bone and its soft tissue covering that
remains often after removal of teeth
Residual ridge resorption (alveolar
resorption) a term to describe the
diminishing quality and quantity of Residual
ridge after the teeth are removed.

Cells of bone
(1)Osteoprogenitor cells migratory stem
cells, mesenchymal in origin,which
develop into osteoblast prior to bone
formation.
(2) Osteoblasts non mitotic cells
responsible for synthesis of bone matrix.
(3)Osteocytes major type of cells of
mature bone
(4) Osteoclasts cells found in areas of
bone resorption in Howships lacunae .

Pathology of residual ridge
resorption
GROSS PATHOLOGY
My Gums Have Shrunk
Reduction in size of bony ridge under the
periosteum.
Lammie in RRR cicatrizing
mucoperiosteum result in pressure
resorption of the underlying bone.this
atrophying mucosa acts as a molding force
that effects a change in the ridge form(JPD
1986)
Classification
ATWOOD 1963
Order I :pre extraction
Order II :post extraction
Order III :high,well rounded
Order IV :knife edge
Order V :low well rounded
Order VI :depressed



Order V /VI shows gross porosity of
medullary bone

FALSCHUSELL 1986

-fully preserved
-moderately wide and high
-narrow and wide
-sharp and high
-wide and reduced in height
-severely atrophic

MISH &JUDY
-abundant bone
-barely sufficient bone
-barely sufficient bone with inadequate width
-compromised bone with inadequate width
-compromised bone with inadequate height
-deficient bone completely flat bone
Basal bone atrophy
Nasal spine may be
resorbed.


DIAGNOSIS
Visualization
Palpation
Panoramic radiograph(Wical &Swoope)
JPD 1974;32;13
2 ratios
(a)b/w the total height of mandible &the amount
of bone below the lower edge of foramen 3:1
(b) b/w the total height of mandible &the amount
of bone below the upper edge of foramen
2.34:1

Extent of bone loss
Class I upto 1/3 rd of vertical height lost
Class II -upto 1/3 rd to 2/3 rd of vertical
height lost
Class III 2/3
rd
or more of mandibular height
lost.
Limitations :
Distorted images of mental foramen
Location of mental foramen
Magnified images


Lateral cephalometric
radiograph(Atwood) JPD1963
Microscopic pathology

Crest of the residual ridge
Osteoclastic activity
Total absence of periosteal lamellar
bone
Thin or no Cortical layer

Interior of residual ridge shows new bone
formation and reversal lines
Pathophysiology of RRR
Physiological process- removal of tooth
Localized pathologic loss of bone
Irreversible
Can extend beyond the alveolar bone
Rate of RRR varies
-between different individuals
-within same person at diff times
-within same person at diff sites
more rapid in first 6 months after
extraction
Carlsson, Pearsson 1967: Pattern of RRR,
established early and maintained through the later
stages
Tallgren, 1972; Atwood and Coy, 1971: Ratio of
RRR in maxillary anterior to mandibular anterior is
1:4
Thus it is more apt to treat a particular patient as
the situation exists rather than going by this
average mean
RRR mucosal, functional, psychological,
esthetic and economic problems
- cumulative- dental cripple
Boucher: Annual rate of reduction in height

-Mandible: 0.1 -0.2 mm/ year, Maxilla : 4 times less

Boucher: Reduction in RR in midsagittal plane
Maxilla: 23 mm, Mandible: 4-5 mm
I mmediate Dentures:1.8 mm bone loss in first yr
Overdentures: 0.9mm bone loss in first year
ETIOLOGY OF RRR
Multifactorial disease

1. Anatomic

2. Metabolic

3. Mechanical

4. Prosthetic

ANATOMIC FACTORS
Amount of bone
Quality of bone
Density of the ridge
Short and square face
Long alveolar process
Bones with muscle attachment






Metabolic Factors
RRR Bone resorption factors
Bone formation factors
Local factors:
Endotoxins
Osteoclast activating factors
Prostaglandins- messengers ( PG E
2
)
Human gingival bone resorption stim.factor
Heparin

Trauma
Systemic Factors:
Decreased bone formation
Patients having excess amounts of
glucocorticoid hormones
Increased resorption
Hypophosphatemia- duodenal ulcer, impaired
renal tubular reabsorption


Estrogen and testeroneANABOLIC
HORMONES.

Adrenal glucocorticoid.including cortisone
and hydrocortisone. ANTIANABOLIC
HORMONES

Excess of ANTIANABOLIC HORMONES
results in faster resorption.

Estrogen antagonizes the effect of PTH retard
bone resorption.
Calcitonin inhibits bone resorption

Wical and Swoope, JPD 1974:
Calcium-Phosphorus ratio above 0.7 in a group with
minimal resorption

Increased Phosphorus- Sec. Hyperparathyroidism

Vit D- increases Calcium absorption from gut,
reabsorption from kidney

Protein deficiency- decreased matrix formation-
osteoporosis

RRR & OSTEOPOROSIS
Type I/ Post menopausal Type II/ Senile
-Extensive corticosteroid therapy can cause
secondary form of disease.
-Acute/chronic oral manifestations.
-Vertebral osteoporosis and periodontal disease.
-Lactose intolerance becomes more prominent.
-750 to 1000 mg/day calcium
-375 IU VIT D2 suggested.



Disuse atrophy

Whendon 1984
Vebelhart,Domenech1995
Constant mechanical stimuli maintain
Coupled cellular activity b/w osteoblast &
osteoclast.
Immobilise bone cannot sustain coupled
remodelling process & result in loss of bone
mass.
In denture wearers mechanical stress are
transmitted through denture base.







Mechanical Factors
Amount of force more in parafunctional habit
Frequency of force
Duration of force
Direction of force
Area over which force is distributed
Damping effect of underlying tissue(Atwood
1979)
RRR x 1/damping effect
mucoperiosteum viscoelastic
bone- maxilla has more cancellous bone
Boucher:
Teeth contact during swallowing are usually
longer duration than with chewing .

Surface area of mandible is 12 sqcm & that
of maxilla is 23 sqcm.















Prosthetic Factors
Broad area of coverage
Decreased number of dental units
Decreased bucco-lingual width of teeth
Improved tooth form
Avoiding inclined plane
Provision of adequate tongue space
Adequate inter-occlusal space

Other Factors
Sex- RRR is more in females( ratio 5:1)
Racial factors-
Garns 1970: Blacks have higher bone density;
Osteoporosis is more in short and high weight females
Time since extraction
RRR x 1/ Time : Carrson and Person, 1967

RRR Anatomical Factors +
Bone resorption factors
Bone formation factors +
Force factors
damping effect factors +
1
Time

Consequences of RRR
Apparent loss of sulcus depth and width
Displacement of muscle attachments
Loss of VDO
Anterior rotation of mandible
Altered inter-ridge relationship
Altered location of mental foramen
Altered facial esthetics
Decreased masticatory function



SUMMARY

T hank you
T hank you

Techniques correct alveolar atrophy


Techniques to compensate for problems
LOWERING THE MENTAL
FORAMEN
Incision along alveolar crest
Mucoperiosteum carefully reflected until
neurovascular bundle emerges from the
foramen.
Vertical grove inferior to foramen 5 to
10mm.
Cortical bridge below nerve removed when
grove completed.
Freed nerve carefully moved into a new
position
Mucosal flap placed and sutered.
Pong Dentures
2 skinned lined pockets in piriform
aperture created.
Horizontal incisions 1cm long down in this
region.
Piriform aperture exposed and nasal
mucosa elevated from floor of nose on
each side to create pocket.
Fabricated pongs inserted to check fit.
Partial thickness skin graft taken and draped
over pongs.
Stent/denture placed till 10 days in vestibular
mucosa.
Patient must keep dentures or separate prongs
in place for 1 year until all fibrotic changes have
taken place
Adjustments made by disclosing areas of
overextension with pressure paste and grinding
areas in question.
Zygomaticoplasty
Removal or compression of bone at butteress of
zygoma to provide vestibular height and lateral
stability.
Horizontal incision made below process.
Mucoperiosteum reflected and a horizontal cut
made with bur at upper aspect of buttress.
3 or 4 vertical cuts made inferior to base of
process
Bone pressed medially into maxillary antrum.
5 to 8 mm of alveolar height can be
achieved.
TUBEROPLASTY
Transverse incision from buccal vestibule
to palatal side made just at distal aspect of
tuberosity.
Pterygomaxillary exposed
Lateral and medial pterygoid separated
from tuberosity.
Segment pushed posteriorly.
VESTIBULOPLASTY
Attempts to expose and make available for
denture construction that bone which is
still present.
Assumption is bone resorption will have
end point and support for denture will
distribute masticatory forces and slow
resorptive process
Clark(1953)
Flap was pedicled from lip
Raw surface is on bone resulting in less
contracture and better healing
How 1966 and kethley and gamble 1978
described lipswitch procedure
Labial mucosa flap developed and
extended to crest of ridge from an initial lip
incision.
Tissue Graft Vestibuloplasty
INDICATIONS
insufficient bone to complement for relapse of
a secondary epithlization
Vestibular depth is needed after bone graft
augmentation.
ADVANTAGES
Reduces wound contracture
Coverage for denuded area
Rapid healing
Early construction of prosthesis
Types of graft materials
Palatal mucosaseverely atrophic
mandible

Buccal mucosa-holding down muscle
attachments and creating smooth
vestibule when bone loss has been
moderate.

Skin for wide coverage



Lingual vestibuloplasty