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R R R :is a localized loss of bone on the crest of residual ridge
Order I -‐ Pre-‐extrac3on Order II -‐ Post-‐extrac3on Order III -‐ high, well-‐rounded Order IV -‐ knife edge Order V -‐ low, well-‐rounded Order VI -‐ depressed
Anatomic factors Metabolic factors Mechanical factors Systemic factor
If a low depressed ridge (order VI) has existed for many years.Anatomic factors The anatomic factors includes things such as size and shape of the ridge. the type of bone and the type of If a ridge has existed as high and well rounded (order III) for several years. future Residual Ridge Resorp3on will probably he at a low rate. mucoperiosteum. . If a residual ridge has gone from an order II to an order IV in span of 2 years. it will likely to con3nue to do so. it will probably con3nue to resort rapidly.
rounded ridges and broad palates would seem to be favorable anatomic factors. .
). Other possible local bone resump3on factor could be related to trauma (especially under ill-‐ﬁQng dentures) which leads to increased or decreased vascularity and changes in oxygen tension. osteoclast-‐ac3va3ng factor (OAF). especially in pa3ent. has been associated with mast cells that has been observed in microscopic sec3ons of residual ridge close to the bone margin. Who do not properly clean their dentures. etc. .Metabolic factors These factors include endotoxins form dental plague (plague occurring in edentulous mouth. Heparin which has been shown to be a cofactor in bone resorp3on.
so pressure under maxillary denture is 121b in 2 and under mandibular denture is 21 Ib/in2. . If pa3ent bites with a pressure of 501b. Residual Ridge Resorp3on & Force As said.Mechanical Factors Bone that is “used” by regular physical ac3vity. there is tendency for there to be more Residual Ridge Resorp3on in the mandible than in maxilla.2 in (ra3o 1. will tend to strengthen within certain limits. So it can be said that there is more of mandibular ridge resorp3on than in the maxilla. WOELFEL et al in his study on a pa3ent made maxillary denture of area 4.8 :1). while bone that is in “desire” will tend to atrophy.
so its energy absorp3on quali3es may inﬂuence the rate of Residual Ridge Resorp3on. The damping eﬀect may take place in the mucoperiosteum which is considered to be viscoelas3c. it may be a factor in the diﬀerences in the Residual Ridge Resorp3on of two jaws. ﬂa`er and more cancellous than mandible.The amount of force applied to the bone may be aﬀected inversely by “damping eﬀect” or energy absorp3on. Overlying mucoperiosteum varies in its viscoelas3c property from pa3ent to pa3ent and from maxilla to mandible. . Damping eﬀect of bone itself should be considered since maxillary residual ridge is frequently broader.
But experimental studies and biologic sciences have shown that alveolar bone reduc3on is basically a systemic disease. i) Bone loss due to decreased forma3on ii) Bone loss due to increased resorp3on iii) Bone loss due to unknown causes. .SYSTEMIC FACTORS IN ALVEOLAR BONE LOSS Most den3sts consider alveolar bone resarp3on to be a local problem and systemic factors are considered to be of secondary importance.
i) Bone loss due to decreased forma3on This is seen mainly in pa3ent with excess amount of glucocor3coid hormones. . Excess secre3on of cor3sol by adrenal glands (Cushing’s syndrome) & in treatment for pa3ent with Rhematoid Arthri3s with large amounts of glucocor3coids. Glucocor3coids inhibit bone forma3on as it suppress external Ca absorp3on). and cause severe osteoporosis Excess glucocos3coids are due to .
. It may occur in pa3ent with duodenal where who are treated with antacids containing aluminum hydroxide gel which binds phosphorous and is unabsorbable b) High parathyroid Hormones (PTH) : It is one of the most important systemic factors inﬂuencing the rate of osteoclas3c bone resorp3on. which causes resorp3on. bone resorp3on. Bone loss due to increased resorp3on a) Hypophyosphatemia : Eﬀect of hypophosphatemia has a direct eﬀect of serum phosphorous on bone to enhance . A slight decrease in serum calcium concentra3on s3mulates the parathysiod gland to secrete PTH.ii.
Treatment of grossly resorbed mandibular ridge .
b. The health of the ridge and the surrounding 3ssue. * Intraoral examina3on a.Prosthodon+c treatment * History and examina3on: -‐ Medical history -‐ Dental history -‐ Examina3on of the exis3ng dentures.Ves3bular depth.2. .
Part of it is available for the lingual ﬂange of the denture. -‐ sublingual fossa. .Alveolingual sulcus: The alveololingual sulcus (the space between the residual ridge and the tongue) extends posteriorly from the lingual frenum to the retromylohyoid curtain. The alveolingual sulcus can be considered in three regions: -‐ Sublingual crescent space. -‐ Retromylohyoid fossa.
Buccal shelf. * Radiographic examina3on. . Iden3ﬁca3on of the interarch-‐space problems. Tongue posi3on. d. g. c. Tonicity of the 3ssue. e. f. Buccal pad of fat.
2.Impression objec3ves: 1.A broad area coverage.A controlled pressure technique would decrease occlusal loading over the aﬀected area and distribute forces more to primary support areas like the mandibular buccal shelf. deceases the force experienced per unit area of the mucosa beneath the denture likehood of its trauma.Impression technique should ensure that the denture ﬁQng surface is smooth and does not cause fric3onal abrasion of the underlying mucosa. However in the grossly resorbed ridge the area of 3ssue available for support is reduced and extension of the base is cri3cal to avoid interference with movement of the border structures. 3. with maximal denture base extension. .
Impression materials and techniques: -‐ An impression material with adequate ﬂow proper3es should be used to void uneven pressure during impression procedures that could result in a localized rebounding eﬀect on the compressed 3ssues under the denture and/or “sore spots”. . Either of these condi3ons could result in uneven sea3ng of the ﬁnished denture and loss of in3mate 3ssue contact. -‐ The impression material should also provide adequate reproduc3on of surface detail to prevent small irregulari3es capable of entrapping air. -‐ The elimina3on of dislodging forces by accurate border molding that prevents overextension should be accomplished.
-‐ A slight generalized pressure on the soj 3ssues is desirable. -‐ Special impression techniques to determine accurately a denture extension with reference to func3oning 3ssue at its denture border have been evolved. Use of a moderately viscous light bodied impression material with suﬃcient ﬂow. . elimina3on of full arch relief spacers in the tray and use of a nonperforated custom tray are among those modiﬁca3ons in in technique that can lead to an impression recording of the 3ssues in a mildly displaced form.
and the impression material is allowed to cure for 10 minutes.-‐ Complete lower dentures made from sta3c impressions and dentures that are not stable may be used eﬀec3vely for making dynamic impressions. Ajer the material has set for 3 to 4 minutes. The 3ssue condi3oning material is mixed carefully and placed over the en3re impression surface of the denture. The denture is inserted into the mouth. the border extension are adjusted and severe undercuts are reduced. the pa3ent sucks and swallow several 3mes. Ajer the occlusion of the denture (which is to serve as a tray) has been tested for deﬂec3ve occlusal contacts. .
.Fibrous 3ssue “Flappy ridge” Overlying the residual ridge. or surgically remove such redundant 3ssue. may compromise denture stability and special techniques have been devised which either load other sites and avoid displacement.
Ver3cal dimension of occlusion: In cases of marked ridge loss the ver3cal dimension may be further reduced in order to place the occlusal table closer to the alveolar ridge and create a more stable lower denture by reduc3on in the height of the denture. .
Denture occlusion General considera3ons 1. 2. 3. Addi3onal forces will be generated by the teeth during contact. cheeks.It is accepted that the occlusion should be balanced in centric rela3on.Destabilizing forces from the lips. together with reduc3on in force per unit area applied to the mucosa. .the teeth should be set over the center of the ridges so that the forces applied to the teeth when occluding and chewing are directed straight through the ridges to seat the dentures ﬁrmly on them. may be achieved with a reduc3on in length of the occlusal table by reducing the number of teeth. an tongue act on the denture polished surfaces and dental arch.Increased denture stability .
improve tooth form to reduce the amount of force required to penetrate the bolos of food 7 . avoidance of inclined planes to minimize dislodgement of the denture and shear force . Decrease bucco-‐lingual width of the teeth 5. 6 .4.stresses to the anterior ridges can be reduced by removal of anterior tooth contacts in centric rela3on closure.
Shaping of polished surfacePost -‐the buccal surface of the lower denture should be concave.to face up and out. the mandibular lingual ﬂange should slope toward the tongue. The use of soj liners Post inser3on follow up .
Implants a.Disrac3on 2.Subperiostal b.Endosseous .Ridge augmenta3on c.enlargement of denture-‐bearing areas a.Transosseous c.Surgical management 1.Ves3buloplasty b.
it is possible to augment the mandible prior to the placement of endosseous implants. Various techniques and materials have been developed to increase mandibular height. .Gra2ing Procedures In the case of severe atrophy of the edentulous mandible. Onlay techniques as well as interposi3on of the graj in the inter-‐foraminal area are used.
and.Autogenous materials. wound dehiscence. and allogenic materials. such as bone and car3lage. are used for ridge augmenta3on The most signiﬁcant complica3ons that occur following grajing procedures in the mandible are sensory disturbances of the mental nerve. donor area morbidity . with autogenous bone grajs. infec3ons of the grajed area. such as hydroxyapa3te or bone subs3tutes. as well as combina3ons of these materials.
mineraliza3on of the newly formed bone matrix in the distrac3on area has progressed suﬃciently to allow for the placement of endosseous implants with suﬃcient primary stability.Between four and eight weeks ajer the last day of ac3ve distrac3on. .
.In comparison with grajing procedures. and the gain of soj 3ssues. but such complica3ons are rarely reported in the literature. the advantages of distrac3on osteogenesis are the absence of donor site morbidity. the presence of vital bone in the distrac3on area. infec3on. and necrosis of the superior fragment. Possible complica3ons of the distrac3on technique for the edentulous (severely resorbed) mandible are fracture of the mandible.
Ridge augmentation by subperiosteal injection of hydroxyapatite .
Distrac3on osteogenesis is a technique of gradual bone-‐lengthening. an osteotomy in the inter-‐foraminal area of the mandible is made.5 to 1 mm per day. allowing natural healing mechanisms to generate new bone. When applied to the reconstruc3on of a severely resorbed edentulous mandible. ajer which the distrac3on device is placed. Five to seven days ajer surgery. . ac3ve distrac3on is started at a rate of 0.
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