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RESIDUAL RIDGE RESORPTION

INTRODUCTION
DEFINITIONS
CLASSIFICATION OF RRR
PATHOLOGY OF RRR
PATHOPHYSIOLOGY OF RRR
PATHOGENESIS OF RRR
EPIDEMIOLOGY OF RRR
ETIOLOGY OF RRR
DIAGNOSTIC AIDS TO DETECT RRR
CONSEQUENCES OF RRR
MANAGEMENT
CONCLUSION

INTRODUCTION

Resorption is defined as loss of tissue substance


through physiologic or pathologic processes. The
tissues remaining following the extraction of the teeth
(Residual alveolar ridge) changes shape and are
reduced in size at varying rates in different individuals
and in the same individual at different times.

DEFINITIONS :

Bone is defined as a highly vascularised, living,


constantly changing, mineralized connective tissue.
[Grays Anatomy]

Alveolar process may be defined as that part of the


maxilla and mandible that form and supports the sockets
of the teeth. [Orbans Dental Histology]

Classification of RRR :

According to Branemark et al in 1985, ridges were


classified on the basis of bone quantity and quality by
radiographic means.

BONE QUANTITY : (Branemark)


Class A : Most of the alveolar bone is present
Class B : Moderate residual ridge resorption occurs
Class C : Advanced residual ridge resorption occurs
Class D : Moderate resorption of the basal bone
Class E : Extreme resorption of the basal bone

BONE QUALITY :
Class 1 : Almost the entire jaw is composed of
homogenous compact bone.
Class 2 : A thick layer of compact bone surrounds a core
of dense trabecular bone.
Class 3 : A thin layer of cortical bone surrounds a core
of dense trabecular bone.
Class 4 : A thin layer of cortical bone surrounds a core
of low-density trabecular bone.

BY WICAL AND SWOOPE :


Class I : Upto one third of the original vertical height
lost.
Class II : From one third to two thirds of the vertical
height lost.
Class III : Two third or more of the mandibular height
lost.

BY KALK AND BAATA :


Degree of alveolar bone resorption in mandible :
Class 0 : Moderate resorption ; both the genial tubercle
and the mylohyoid lines are below the level of the
alveolar ridge.
Class 1 : High degree of resorption ; the genial tubercle
and the mylohyoid are either just below the highest point
of the alveolar ridge or at the same level.
Class 2 : Extensive resorption ; the genial tubercle is
above the level of the alveolar ridge, and the mylohyoid
lines are at the same level or above the alveolar ridge.

Degree of alveolar bone resorption in maxilla :


Class 0 : Little, if any, resorption with there being a
difference in height between the lowest point on the
mucosal membrane and the highest point on the alveolar
ridge. There is no flabby ridge.
Class I : Extensive degree of resorption. The alveolar ridge
is narrow and there is little difference in height between the
lowest points on the mucosal membrane and palate and the
highest point on the alveolar ridge. There may be a flabby
ridge.

NIELS CLASSIFICATION :
Class 1 : Approximately 0.5 inch of space exists between
mylohyoid ridge and floor of mouth.
Class 2 : Less than 0.5 inch of space exists between
mylohyoid ridge and floor of mouth. This is favorable for
lower denture.
Class 3 : The mylohyoid muscle is at the same level as
the mylohyoid ridge. Retention of the lower denture is
almost impossible.

ATWOODS CLASSIFICATION :
Order 1 : Pre-extraction
Order 2 : Post-extraction
Order 3 : High, well rounded
Order 4 : Knife-edge
Order 5 : Low, well round
Order 6 : Depressed

MERCIERS CLASSIFICATION :
Group 1 : High crestal muscles and non resorbed ridge.
Group 2 : Painful atrophic ridge
Group 3 : Absence of residual ridge

ZELSTERS CLASSIFICATION :
Group 1 : High muscle attachment & minimal RRR.
Group 2 : Severe residual ridge resorption with pain.
Group 3 : Absence of residual ridge.
Group 4 : Severe resorption of basal bone.

MISCHS CLASSIFICATION : Based on bone density.


BONE -DENSITY
D1 -Dense cortical bone.
D2 -Thick dense to porous cortical bone on crest and
cortical tabecular bone with in.
D3 - Thin porous cortical bone on crest and fine
trabecular bone with in
D4 - Fine trabecular bone
D5 - Immature, non mineralized bone

Classification according to the American college of


prosthodontists :
1. Based on Bone Height (Mandible only)
Type I : Residual bone height of 21 mm or greater
measured at the least vertical height of the mandible.
Type II : Residual bone height of 16 - 20 mm measured at
least vertical height of the mandible.
Type III : Residual alveolar bone height of 11 - 15 mm
measured at the least vertical height of the mandible.
Type IV : Residual vertical bone height of 10 mm or less
measured at the least vertical height of the mandible.

COMPOSITION OF BONE
CELLS OF BONE
Osteoprogenitor cells
Osteoblast cells.
Osteocytes
Osteoclast cells.

ORGANIC PART 33% - 35%


Collagen 88% - 90% (Type I)
Non collagen 10% - 11%.
Glycoproteins 6% - 9% (Mono, Di, Poly and
Oligosaccharides).
Proteoglycanes 0.8% (sulfated and Non
sulfated)
Sialoproteins 0.35%
Lipids 0.4%

INORGANIC PART 65% - 67%


Calcium & Phosphates 95%
(Hydroxyapatite Crystals Ca10(Po4)6 (OH)2)
Magnesium
Trace elements Nickel, Iron, Fluoride, Cadmium,
Magnesium, Zinc and Molybdenum.

OSTEOBLASTS
*Uninucleated cells that synthesize both collagenous and
noncollagenous bone protein.
*They are responsible for mineralization and are derived
from a multipotent mesenchymal cell.
*They constitute a cellular layer over the forming bone
surface.
*Osteoblasts exhibit high levels of
alkaline phosphate on the outer
surface of their plasma
membranes.

**Other enzymes that participate in their activity are


*ATPase and pyrophosphates
*Type I and type V collagen
*Several noncollagenous proteins,
*A variety of cytokines.

OSTEOCYTE
*As osteoblasts secrete bone matrix, some of them become
entrapped in lacunae and are then called osteocytes.
*The number of osteoblasts that become osteocytes varies
depending on the rapidity of bone formation.
*The more rapid the formation, a more osteocytes are
present per unit volume.

OSTEOCLAST
*Compared to all other bone cells and their precursors, the
multinucleated osteoclast is a much larger cell.
*They are generally seen in a cluster rather than singly.
*Osteoclast is characterized by acid phosphatase within its
cytoplasmic vesicles and vacuoles, which distinguishes it
from other giant cells and macrophages.

*Osteoclast are also rich in lysosomal enzymes.


**Typically osteoclasts are found against the bone
surface occupying shallow, hollowed out
depressions, called Howships lacunae.

Thus the sequence of resorptive events is considered to be


Attachment of osteoclasts to mineralized surface of bone.
Creation of a sealed acidic environment through action of
the proton pump, which demineralizes bone and exposes
the organic matrix.
Degradation of this exposed organic matrix to its
constituent amino acids by the action of released
enzymes.
Uptake of mineral ions and
amino acids by the cell.

CLASSIFICATION OF BONE
1. According to density as
*Compact bone
*Trabecular bone.
2. According to bone mass
*Fine Trabeculae,
*Coarse Trabeculae,
*Porous Compacta and
*Dense Compacta.
3. Microscopically bones are composed of
*Woven bone,
*Lamellar bone,
*Bundle bone and
*Composite bone.

Woven bone
Highly cellular.
Formed rapidly (30-50 m/ day or more) in response
to growth or injury.
Low mineral content.
Random fiber orientation and minimal strength.
Stabilize unloaded Endosseous implants during
initial healing.

Lamellar bone
Principle load bearing tissue of adult skeleton.
Predominant component of mature cortical and
trabecular bone.
Formed relatively slowly (<1 m/ day).
Densely mineralized and highly organized matrix.

Bundle bone
Characteristic of ligament and tendon attachments
along bone-forming surfaces.
Sharpeys fibers from adjacent connective tissue
insert directly into bone.
Bundle bone is formed adjacent to the periodontal
ligament of natural teeth.

Composite bone
High quality lamellar bone deposited on a woven
bone matrix.
Got adequate strength for load bearing.
Important in achieving stabilization of an implant
during the rigid integration process.

**Alveolar Bone forms the bony sockets of the jaw bones


in which the roots of the natural teeth are suspended by
the attachment of the periodontal ligament fibers
(Gomphosis )
**Some alveolar bone is formed during tooth development,
but the majority of alveolar bone formation occurs during
tooth eruption.

*The presence of alveolar bone in the jaw bones is


totally dependent on the roots of the natural teeth;
without the teeth the alveolar bone need not exist.

PATHOLOGY OF RRR
GROSS PATHOLOGY :
Patient has expression My gums have shrunk
Basic structural change is reduction in size of bony ridge
under the mucoperiosteum
Localized loss of bone structure
Overlying mucoperiosteum
Excessive & redundant

No redundant soft tissue

Difficult to understand
Lammie postulates

LAMMIE postulates ; one factor in RRR may be a


cicatrizing mucoperiosteum that is seeking a reduced area
, resulting in pressure resorption of the underlying bone
Longitudinal radiographic cephalometric studies have
provided excellent visualisation of gross patern of bone
loss from lateral view point

Careful superimposition of portions of tracings of


lateral ceph. With reduction of bone in size and shape

Gross anatomic studies of dried jaw bones have shown a


wide variety of shapes and sizes of residual ridges
A simplified method for categorizing residual ridge form
is order 1----order 6

Uses : useful clinically as well as for research purpose


: helps to differentiate various stages of RRR in pts.

In dry specimens

*External cortical surface of maxilla and mandible


are uniformly smooth & crestal area of residual ridge
shows porosities and imperfections
*Bones with more severe RRR display gross porosities
of medullary bone on the crest of ridge

Gross bone loss of residual ridge revealed by superimposition of


portion of two cephalometric radiographs made 16 years apart

RRR does not stop with the residual ridge but may go
well below where the apices of teeth are
There can be a thin cortical plate on inferior border
of mandible or virtually no maxillary alveolar
process

Panoramic radiograph showing severe RRR in both


maxilla and mandible in contrast to dentulous area
that support three mandibular teeth

Radiographs of mid-saggital sections of eight


mandibles illustrating various orders of residual
ridge form
Atwood DA JPD 1971 Vol.26

Clinical examination of ridge form


depends

on

Good judgment of clinician


Palpation in the mouth accurately determines
underlying bone
Lateral ceph. determines amount of bone and rate of
RRR over a period of time
Panoramic radiographs simple & useful method of
estimating amount of RRR

*Original alveolar crest ht. can be predicted by


measurement of distance from inferior border of
mandible to mental foramina
Wical and Swoope

MICROSCOPIC PATHOLOGY :
Evidence of osteoclastic activity on the external surface of
crest of residual ridge
Scalloped margins of howships lacunae contain visible
osteoclasts

Why there is only decrease in size


of residual ridges ???
Reason :
Scalloped external surface contain
osteoclasts only
External surface of bone is
covered by fibrous non osteogenic
periosteum

ATWOOD DA : JPD 1963


There is wide variation in configuration density and porosity
of not only residual ridge but also entire cross-section of
anterior mandible
Mandibular osteoporosis occurs with
Increased variation in density of osteons
Increased no. of incompletely closed osteons
Increased endosteal porosity
Increased plugged osteons

**Remodeling changes occur in the mandible that


account for the typical edentulous facial anatomy.
The overall length of the mandible does not decrease but
may in fact increase as new bone is added to the mental
protuberance, thus accentuating the chin point.

There is an anterior displacement of the mandible


(protrusive position) because of residual ridge
reduction, mandibular rotation (Change in the
angulation of the body relative to the mandibular
ramus), and deposition of bone in the mental region.
Reduction in the residual ridges occurs in an inferior
direction in the molar and premolar areas, but in both
an inferior and lingual direction in the incisor region.
There is generalized thinning of the anterior and
posterior aspects of the mandibular ramus.

PATHOPHYSIOLOGY OF RRR
BONE REMODELLING

OSTEOBLAST
S
BONE FORMATION

OSTEOCLASTS
BONE RESORPTION

Exceeds in case
of

Exceeds in case of

*GROWTH

*PDL DISEASE

*OSTEOPOROSIS

RESIDUAL RIDGE RESORPTION

PATHOLOGIC
PROCESS??

PHYSIOLOGIC
PROCESS??

Bone once lost cannot be


built back by removing
causative factors

Removal of tooth
eliminates the raison d
etry for alveolar bone

Clinical facts :1. RRR not inevitable


2. RRR varies & can proceed far beyond alv.
bone
Practical terms rate of resorption so much that
patient ends up with no cortical bone at crest of
ridge

EXTERNAL OSTEOCLASTIC ACTIVITY

ENDOSTEAL BONE FORMATION


Fails to keep pace
Absence of cortical layer of
bone
Exposure of medullary layer
to external surface
Defects on the crest of
ridge

Pathogenesis of RRR:
RRR is a chronic progressive irreversible cumulative disease which
proceeds slowly over a long period of time from one stage to next

Carlson and Pearson at al


Post extraction study of mandibular bone loss
Pts. with
Least
RRR
Mean
RRR
Most
RRR

First 2
yrs

First 5 yrs

3 to 5 yrs

0.75

0.4

0.13

2.7
5
4.5

1.36

0.5

2.9

1.8

**measurments in
mm

Tallgren Atwood & Coy studied rate of residual ridge


resorption for 25 years
Mean ratio of anterior maxillary RRR to anterior
mandibular RRR was 1:4
RRR is more in mandible than in maxilla and
reverse can also occur
So one must treat the PARTICULAR PATIENT,
NOT THE AVERAGE PATIENT

EPIDEMIOLOGY OF RRR :
Methods
Longitudinal cephalometric; time consuming
and expensive
Panoramic methodology or radiograph
By palpation
There have been no large scale studies of RRR
Longitudinal cephalometric studies of few subjects
have been done
Methods of Measure Bone Formation: Tetracycline labeling
Bone seeking tracer such as Ca-45.

RRR occurs worldwide in

Males and females


Young and old
Sickness and health
With or without dentures
Unrelated to primary reason for the extraction of teeth
( caries & pdl disease )

Studies also suggest incresed knife edge tendency


(KET) in mandibular residual ridge in women
compared to men.

KET = Change in area /Change in height

As Age Advances
Mineral content in bones
Increase

Decrease

MALES

FEMALES

Due to osteoporosis that takes place in females


Leading to knife edge ridges

Etiology of RRR :
RRR is a multifactorial biochemical disease caused
by a combination of
ANATOMIC FACTORS
MECHANICAL FACTORS
METABOLIC FACTORS
(1998 by Leili Jahamgeri )
PROSTHETIC FACTORS
GENETIC FACTORS

Anatomic

Metabolic

Mechanical

1. ANATOMIC FACTORS
RRR ANATOMIC FACTORS LIKE
SIZE & SHAPE OF RIDGE
TYPE OF BONE REMOVED
AMOUNT OF BONE
QUALITY OF BONE
SPACES BETWEEN RIDGES
MUSCLE ATTACHMENTS
ACTION OF TONGUE

2. MECHANICAL FACTORS
RRR
FORCE
DAMPING EFFECT
F

Amount

Duration

Frequency

Direction &

Distribution

Dampening effect takes place in the


mucoperiosteum, which is a viscoelastic material.
Maxillary bone (RR) is frequently broader, flatter
and more cancellous than its mandibular
counterpart. So it is ideally constructed for the
absorption and dissipation of energy.
Frost pointed out that the trabacule in cancellous
bone are arranged parallel to direction of
compression deformation.

METABOLIC FACTORS :
RRR

BONE RESORPTION FACTORS


BONE FORMATION FACTORS

BONE RESORPTION FACTORS


LOCAL
-Endotoxins from dental
plaque
-Osteoclast activating
factor
-Prostaglandin
-Heparin
-Trauma

SYSTEMIC

Estroge
n

- Correct amount of
circulating
- Osteoporosis

Androge
n
Thyroxin
e

- Hypophosphetemia
Vitamin- Parathormone
- Calcitonine

D
Flouride

PROSTHETIC FACTORS

INCREASED OCCLUSAL FORM


VERTICAL DIMENSIONAL CHANGES
CUSP FORM
EXCESSIVE LOAD BY OVERLY FITTING DENTURES

OTHERS :
BONE LOSS DUE TO UNKNOWN CAUSES
AGE RELATED BONE LOSS
GENETIC FACTORS
DRUG THERAPY

RRR ANATOMIC FACTORS +


BONE RESORPTION FACTORS + FORCE
BONE FORMATION FACTORS DAMPING
In addition to the three major categories of factors
(anatomic, metabolic and mechanical), the importance
of time since extraction to the bone loss should be
emphasized by adding in an inverse ratio.
RRR ANATOMIC FACTORS +
BONE RESORPTION FACTORS + FORCE
BONE FORMATION FACTORS DAMPING
+ 1
TIME

Various etiologic factors and their correlation


Etiologic factor
Correlation with RRR
Source
Anatomic
factor
Mandible
Short & square
face
Large alv.
process
Density of
alveolar bone
Labial
alveoloplasty

4 x more RRR than


max.
Increased RRR

*Tallegren
*Atwood &
coy
*Tallegren

Increased RRR

*Wictorin

No correlation of RRR
with bone density

*Wilson

Increased RRR

*Atwood &
coy
*Gazabatt et
al
*Wictorin

Various etiologic factors and their correlation


Etiologic factor
Correlation with RRR
Source
Prosthodonti
cImmediate
Decreased RRR
dentures
Overdentures
Zero degree
teeth

Decreased RRR
Increased RRR

*Wictorin
*Carlson et
al
*Crum &
Rooney
*Winter et
al
Woelfel et
al

Metabolic and systemic factors


Etiologic factor
Correlation with RRR
Age & sex

No correlation with
the rate of RRR

Osteoporosis

No correlation with
the ridge height
Smaller max. ridge

Calcium & vit


D supplement
Sodium flouride
supplement

Knife edge type


mandible
Decreased RRR
No correlation but
better calcification

Source
*Atwood &
Coy
*Wictorin
*Carlson et
al
* Atwood &
Coy
*Nishimura et
al
*Mercier &
Inoue
*Wical &
Brussee
Fenton & ElKassem

Functional factors
Etiologic factor
Correlation with RRR
Intensive
denture
wearing
Regular denture
wearing
Other factors
Bioelectric
potential

Increased RRR
Combination
syndrome
No correlation with
the rate of RRR
Statistically
insignificant trend
Decreased RRR by
exogenous pulsed
electromagnetic
field in dogs

Source
*Campbell
*Kelly
*Carlson et
al
* Atwood &
Coy
*Bergman
*Nicol et al
*Van der
Kuij et al

DIAGNOSTIC AIDS TO DETECT RRR


Radiographic : widely used to detect bone
resorption and formation by taking periodic
radiographs.
Tetracycline labeling : Injected into the body
through oral or pariental administration and
should be repeated 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 as tetracycline
calcium chelate formed is fluoroscent and can be
viewed by fluorescence microscopy.

Mercury porosimetry : Osteocytes are also capable


of bone resorption (i.e. periosteocytic lacunar bone
resorption).
To determine the quantitative importance of
osteocytic resorption 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.

PG s AS MEDIATORS OF
RRR

PROSTAGLANDINS: MEDIATOR OF RRR


Prostaglandins (PG) has been demonstrated to mediate bone
resorption in vitro and in vivo. PG is not stored in cells in their
final form but is quickly released in response to mechanical,
physiologic and pathologic stimuli.
Its half life is short (less than 1min) and its various effects are
limited only to adjacent cells, therefore it is important to note
that PG works as a local hormone.
The pharmacologic effect of NSAIDs such as indomethacin
that are known to be inhibitors of PG bio synthesis have been
investigated in order to control bone resorption in orthodontic
tooth movement and in periodontal disease.

PROSTAGLANDINS: MEDIATOR OF RRR


These findings indicate that PG may have an important
biologic role in the pathophysiology of localized bone
resorption in the oral cavity.
Bone resorption is a cellular phenomenon in which osteoclasts
remove calcified substances from the bone.

It is hypothesized that osteoblasts are involved in bone


resorption by coupling with osteoclasts, because the cellular
receptor against various bone resorbing hormones (including
PG) have been found in osteoblasts but not in osteoclasts.

PROSTAGLANDINS:

MEDIATOR OF RRR

PGs are released from many kinds of cells including


inflammatory cells such as neutrophilic granulocytes and
macrophages as well as local mesenchymal cells such as
osteoblasts and cells of the periodontal ligament. Mechanical
stimulation of osteoblastic cells in vitro caused a significant
elevation cAMP and PG synthesis.
These findings may suggest the connective tissue contraction
associated with extraction site and afterwards towards the crest
of the residual ridge. The phenomenon may explain a
mechanism of localized bone resorption at the crest area of the
residual ridges by the PG activities. The continuous and
localized bone resorption in RRR may be caused by continuous
synthesis of local PG.

OSTEOPOROSIS
Osteoporosis is a systemic disease in the elderly.
Osteoporosis shows a decrease in the skeletal mass
without alteration in the chemical composition of
bone.
Loss of the spongy spicules of bone that support the
weight bearing parts of the skeleton can be seen in
radiographs of regions of the skeleton that bear
heavy loads, such as the vertebral column, epiphysis
of long bones, the mandible and the fingers.

OSTEOPOROSIS
Osteoporosis is common in aging individuals,
especially post menopausal women when the
estrogenic blood level is low.
In elderly men and women, osteoporosis is caused by
a variety of factors such as calcium loss, calcium
deficiency, hormonal deficiency, change in protein
nutrition and decreased physical activity.
Progressive loss of alveolar bone may be a
manifestation of osteoporosis

Consequences of RRR :
Apparent loss of sulcus width and depth.
Displacement of muscle attachment close to the ridge.
Loss of vertical dimension of occlusion.
Reduction of the lower face height.
An anterior rotation of the mandible.
Increase in relative prognathia
Changes in inter alveolar relationship following RRR

Morphological changes of the alveolar bone such as


sharp, spiny uneven residual ridges.
Location of mental formina close to the ridge crest.

Prosthodontic treatment modalities :


1. COMPLETE DENTURES
Well fitting complete dentures
Exerts Pressure on the alveolar
bone
Favourable
Preserves alveolar
bone

Unfavourabl
e
Resorption of alveolar
bone

Campbell et al ( 1973 )
Edentulous patients wearing dentures had smaller
residual ridges as compared to those not wearing
dentures

WHY THERE IS MORE RESORPTION SEEN IN


MANDIBLE THAN MAXILLA ???
1. Mandible provides a smaller surface area of support
for the dentures
2. Amount of cancellous bone is lesser as compared to
maxilla
*Dentures help to preserve the horizontal dimensions of
residual ridge to some extent & vertical dimensions
undergo resorption especially in mandible( 4 times)
* Irreversible alveolar bone loss results from extraction
regardless of how soon a denture is provided
( Atwood DA )

For maxilla
Extent of alveolar bone loss is a function of
composition of opposing dentition
Maxilla opposing natural mandibular anteriors
Less resorption
Maxilla opposing artificial mandibular anteriors
More resorption
Combination syndrome
**More resorption in anterior mandible seen in patients
. wearing dentures day and night

2. OVERDENTURES :
Distribute masticatory load between edentulous ridge
and abutment
Transfer occlusal forces to alveolar bone through
periodontal ligament of retained roots
Proprioceptive feedback from pdl prevents RRR
Crum & Rooney et al
Measured the mean vertical bone loss in anterior
mandible of 5.2 mm after 5 years for immediate
dentures as compared to 0.6mm for immediate
overdentures

3. REMOVABLE PARTIAL DENTURES :


Loss of periodontal attachment & marginal bone loss
adjacent to abutment
Patients

Free of pdl disease


Adequate plaque control
Minimum bone loss occurs

**Occlusal problems occurs within 5 years as a result


of vertical RRR with distal extension bases

4. FIXED PARTIAL DENTURES :


Marginal bone loss is minimum & is almost same as of
uninvolved teeth
Mean annual rate of bone loss ~ 0 mm for up to 15
years if adequate plaque control is maintained

5. IMPLANT SUPPORTED PROSTHESIS:


Majority of bone loss (1-2mm ) occurs during healing
and remodelling periods
Annual bone loss with implants is 0-0.08mm
BONE LOSS
Implant supported
overdenture
Maxilla
Single implant
prosthesis

Implant fixed
prosthesis

>

Mandible

>

Multiple
implant
prosthesis

Why more bone loss in maxilla with implants???


Poor bone quality in maxilla
Increased mucosal irritation surrounding shorter
abutments required

Jacob et al
11 % reduction in bone ht. distal to implant overdenture
4 % reduction in bone ht. distal to implant fixed
prosthesis

Management of RRR

1) Two important factors to be considered are ;


1. Attitude of the patient
2. Role of any systemic diseases as etiologic factors

PREVENTION OF RRR
Preventing loss of teeth
Correct diagnosis & management of etiologic factors
Correct hormonal & nutritional deficiencies if any.
Remove dentures for atleast 8-12 hours for tissue rest
Bitting with fork & knife i.e placing small masses of food over
posterior teeth ( Heartwell )

Management
1)Treatment of systemic factors involved in RRR
2)Prosthodontic management

a) Methods to improve denture foundation


b) Design of the dentures
c) Impression procedures
d )Other options ;
Overdentures
Submerged roots
Hollow dentures
Metal based dentures

3)Surgical management

1)Treatment of systemic factors involved in RRR


Role of systemic disease as an etiological factor in
gross alveolar resorption must be considered
Systemic conditions like osteoporosis, hormonal
imbalance and dietary deficiencies plays an
important role in RRR
Prosthodontist should always consider the possibility
of systemic cause for gross alveolar resorption

2. Prosthodontic management

Oral tissues - change shape with time


Pressure transmitting surface
Poorly adapted to the oral mucosa
Resulting in
Deformation of the denture supporting tissues
Must be corrected

A)METHODS TO IMPROVE DENTURE FOUNDATION

Use of temporary soft liner


Regular finger massage of denture bearing mucosa
Rest for denture supporting tissues
Correction of old prosthesis to restore VD
Good nutrition especially for geriatric patients
Conditioning of patients musculature by jaw exercises ,
co-ordination &
Preparing the patient psychologically

A course of treatment with tissue conditioning


materials is often indicated.
These materials allow deformed tissues to resume
their normal shape
Abraded artificial teeth cause loss of facial height
Failure to carry out such corrective therapy can
result in continuing distortion of oral tissues by
dentures

B) DESIGN OF THE DENTURE ;


a)Broad area of coverage to decrease force per unit area
( SNOW SHOE EFFECT )
b)Decrease number of dental units & decreased buccolingual width of teeth ( decreased force to penetrate
bolous of food )
c)Avoidance of inclined planes ( to minimise dislodgement
of denture & shear forces )
d) Centralization of occlusal contacts ( to increase
stability & maximise compressive forces )
e)provision of adequate tongue room & adequate interocclusal distance

f) morphology of occlusal table ;

Anatomic vs Non anatomic teeth


Kyadd (1960 ) found that 33 o & 200 teeth caused
more deformation and lateral stresses on the
ridge than non anatomic teeth ( Cusp Trauma )

g) occlusal pattern ;
Cuspless flat plane occlusion
Anatomic teeth with compensating curves
Careful setting & selective grinding to minimise
lateral stresses

h) Muscular Control ( Neutral Zone )


Gardette (1800 ) first noted potential
of muscular forces in denture control
Fish (1933) introduced concept of denture control
The secondary supporting surface i.e polished
surface should have their shape determined by oral
musculature ( neutral zone )
i ) Tooth Material
Acrylic vs Porcelein
The property of transmission of impact forces is
more important than wear resistance when
considering health of alveolar ridges

Acrylic teeth

Cushioning effect

Absorbs more forces than porcelein teeth


PLUS
Denture base material acrylic or metal

C ) IMPRESSION PROCEDURES ;
Bernard Levin ---Primary impression made with
alginate and less water ( 25 % )
Mac Cold & Tyson ( BDJ 1997 )---Use of
admixed technique for impressions ( 3:7 )
Functional reline technique---use of open and close
mouth procedures
Procedures for severely atrophied mandible (JPD
1993 ; 73 : 574 )--- peripheral borders are developed
functionally with tissue conditioning material and
final impression is taken with polysulphide
impression material

Other options
Overdentures :distribute masticatory load b/w
edentulous ridge and abutment
Rate of bone loss 0.8 mm in first year
Submerged roots : vital or non-vital
prevents resorption of ridges
Hollow dentures;
( JPD 1988 ; 59 :4)
Used in advanced atrophy of maxilla with
adequate interocclusal distance
Double flask technique of Challian & barnetts is
used for maxilla ( weight reduction 25 % )
Holtz technique with modifications for mandible

Metal based dentures ;


( JPD 1987 ;57:6 )
Metal based denture with soft liner is advocated in
patients with severely atrophic residual ridges
Metal base provides
Weight necessary to facilitate retention
Maintain Adequate strength with modest
extensions
The soft liner accomodates ridge irregularities and
changes

Exercise stimulation of edentulous areas


Exercise stimulation is a practical & desirable part of
complete denture therapy.
Exercise stimulation for a period of 12 weeks is usually
adequate in most severe cases.
If bone reorganization is accomplished by frequently
induced intermittent stimuli, the supporting structures
can be prepared for the occlusal function within limits
of individual tolerance
Intermittent use of Exogenous pulsed electromagnetic
fields is demonstrated the effectiveness in decrease in
the rate of residual ridge resorption

Dietary guidelines for patients at risk of losing bone


Maintain a high daily calcium intake
Obtain four servings of low fat dairy foods or
obtain equivalent amounts of calcium daily
Take calcium supplements if dietary intake is low
Choose calcium citrate maleate if patient has
achlorhydria
If lactose intolerant, treat milk with lactase tablets
or drops

Dietary guidelines for patients at risk of losing bone


Prevent negative calcium balance
Limit daily alcohol and caffeine intake
Consume about 6 ounces of protein from meat,
poultry and fish
Use small amounts of processed foods high in
sodium

Dietary guidelines for patients at risk of losing bone


Obtain 4000 I.U of Vitamin D daily
Spend 15 minutes in the sun 3 times a week
Choose a multivitamin or calcium supplement that
contains 4000 I.U of Vitamin D.
Discuss calcium or drug interactions that interface
with calcium bioavailability with the physician

Nutrient

Effect

Calcium

Increases

Vitamin D

Increases

on metabolism

bone mass, decreases rate of bone loss in post


menopausal women
intestinal absorption of calcium, decreases bone
resorption.

Phosphorus High intake may increase calcium urinary loss

Sodium

High

intake increases urinary calcium losses

Fluoride

Stimulate

Caffeine

High

Alcohol

High

osteoblasts, increases trabecular bone mass.

intake increases calcium urinary losses

intake accelerates menopause, toxic effects on


osteoblasts, increased calcium urinary losses

Surgical treatment

Preprosthetic surgery includes ;


Ridge preservation procedure as a preventive measure
Corrective or recontouring procedures of the defects
and abnormalities
Ridge extension procedures
Relative methods e.g., sulcus extension
(vestibuloplasty)
Absolute methods e.g., ridge augmentation method

Surgical treatment
Reconstruction methods like correction of abnormal
ridge relationship
Provision of accessory undercuts
Creating favourable undercuts
Modified denture construction procedure e.g.,
immediate denture where construction of the denture
proceeds surgery

Ridge augmentation
It is aimed at :
Increase in the ridge height and width providing a
large denture bearing area ,
Protection of neuro vascular bundles
Restoration of proper maxillomandibular arch
relationship.
Ridge augmentation has been tried with:
Bone transplants
Autogenous and homogenous cartilage
Hydroxyapatite porous replamine form
Acrylic implants.
Tri calcium phoshpate

IMPLANTS ;
ADVANCED RRR: Surgical management ( IJP 1993)
With introduction of osseointegration by Branemark
reconsrtuction of advanced RRR has become a
successful procedure
The various problems associated with RRR and
stability of removable soft tissue borne dentures have
aroused interest in dental implantology to provide
stable mechanical support to the dental prosthesis.

IMPLANT SUPPORTED PROSTHESIS.


Maintenance of alveolar bone
Maintenance of occlusal vertical dimension.
Height of alveolar bone is found to be maintained as
long as the implant remains healthy.
Improved psychological health.
Regained proprioception.
Increased stability, retention and phonetics.

Maintenance of structure and function of muscles of


mastication and facial expression.
Immune to caries.
Overall volume of bone is maintained.
Efficiency to take up stress and strain.
There is 20 fold decrease in the loss of structure with
implants when compared with resorption that occurs
with removable prosthesis.

CONCLUSION :
The etiology of residual ridge resorption is a subtle
combination of local and systemic factors, but the exact
processes involved are poorly understood.
There is no reliable clinical measurement, which might
predict the future rate of alveolar ridge resorption in a
particular edentulous patient.

The best possible method is to preserve as many teeth


or roots, as possible, followed by over-dentures which
may act as effective means of preserving adjacent
alveolar bone.
The use of endosseous implants to support fixed or
removable prostheses has been shown to preserve
adjacent remaining alveolar bone. But as with
natural teeth, implants are not immune to bone loss.