1) INTRODUCTION

The alveolar process is the bone that forms and supports the tooth
sockets (alveoli). It forms when the tooth erupts in order to provide the
osseous attachment to the forming periodontal ligament; it disappears
gradually when the tooth is lost. The process of residual ridge resorption
starts soon after the dental extraction / lost following the extraction of teeth
the bony socket and ad!acent soft tissues undergo a series of tissue repair
reactions including acute inflammation. "apid restoration of epithelial
integration and connective tissue remodelling. #istologic evidence of
active bone formation in the bottom of the socket and prone resorption at
the edge of the socket are seen as early as $ weeks after the tooth extraction
and the socket is progressively filled with newly formed bone in about %
months. "apid bone remodelling subsides by this time but continuous bone
resorption may persist at the external surface of the crestal area of the
residual alveolar bone resulting in considerable morphologic changes of
bone and overlying soft tissues over the years. This phenomenon has been
described as the "&'()TI*+ *, "&-I'(./ "I'0&- or "&-I'(./
"I'0& "&-*"1TI*+ (""").
2) NORMAL ALVEOLAR BONE PHYSIOLOGY
.lveolar bone is formed during fetal growth by intramembraneous
ossification and consists of a calcified matrix with osteocytes enclosed
within spaces called lacunae. The osteocytes extend processes into
canaliculi that radiate from the lacunae. The canaliculi form an
anastomosing system through the intracellular matrix of the bone which
brings oxygen and nutrients via the blood to the osteocytes extensively and
travel through the periosteum. The endosteum lies ad!acent to the marrow
2
vasculature. 3one growth occurs by apposition of an organic matrix that is
deposited by osteoblasts.
The alveolar process consists of the inner socket wall of thin
compact bone called the4
a) .lveolar bone proper ()ribriform plate).
b) -upporting alveolar bone which consists of cancellous trabeculae and
the facial and lingual plates of compact bone. The interdental septum
consists of cancellous supporting bone enclosed within a compact
border.
The alveolar process is divisible into separate areas on an anatomic
basis but it functions as a unit.
.ll parts are interrelated in the support of the tooth. *cclusal forces
that are transmitted from the periodontal ligament to the inner wall of the
alveolus are supported by the cancellous trabeculae which in turn are
buttressed by the labial and lingual cortical plates.
The below diagram show the relative portions of cancellous bone
and compact bone that form the alveolar process.
$
5ost of the facial and lingual portions of the sockets are formed by
compact bone alone; cancellous bone surrounds the lamina dura in apical
apicolingual and interradicular areas.
.lthough the alveolar bone tissue is constantly changing in its
internal organi6ation it retains approximately the same form from
childhood through adult life. 3one deposition by osteoblasts is balanced by
resorption by osteoclasts during the processes of tissue remodelling and
renewal.
The bone matrix that is laid down by osteoblasts is not minerali6ed
and is referred to as prebone or osteoid while new osteoid is being
deposited the older osteoid located below the surface becomes minerali6ed
as the minerali6ing front advances.
1rior to becoming minerali6ed bone matrix collagen becomes coated
or associated with a glycoprotein (or proteoglycan) opa7ue granular
substance. It is conceivable that this material together with other matrix
constituents. . similar series of event is believed to occur during dentin
matrix production and minerali6ation.
*steoclasts are large multinucleated cells that are often seen on the
surface of bone within eroded bony depressive referred to as #owship8s
lacunae. The main function of these cells is consisted to be resorption of
bone when they are active as opposed to resting they possess an
elaborately developed ruffled border from which hydrolytic en6ymes are
believed to be secreted. These en6ymes digest the organic portion of bone
the activity of osteoclasts and the morphology of the ruffled border can be
9
modified and regulated by hormones such as para hormone and calcitonin.
The origin of osteoclasts is still a matter of speculation and controversy.
-mall mononucleated cells have also been described as bone
resorbing cells.
The cancellous portion of the alveolar bone consists of trabeculae
that enclose irregularly shaped marrow spaces lined with a layer of thin
flattened endosteal cells. There is wide variation in the trabecular pattern of
the cancellous bone which is affected by occlusal forces. The matrix of the
cancellous trabeculae consists of irregularly arranged lamella. -eparated by
deeply staining incremental and resorption lines indicative of precious bone
activity with an occassional haversian system.
Vascular supply : The cribriform plate of the tooth socket appears
radiographically as a thin radiopa7ue line termed the lamina dura which is
lost after the loss of the tooth. 3ut when present it is perforated by
numerous channels containing blood lymph vessels and nerves which line
the 1/ with the cancellous portion of the alveolar bone the vascular supply
of the bone is derived from blood vessels branching off of the superior or
inferior alveolar arteries. These arterioles enter the interdental septa within
nutrient canals together with veins nerves and lymphatics. 'ental
arterioles also branching off of the alveolar arteries send tributaries
through the 1/ and some small branches enter the marrow spacer of the
bone via the perforations in the cribriform plate. -mall vessels emanating
from the facial and lingual compact bone also enter the marrow and spongy
bone.
In contrast to its apparent rigidity. .lveolar bone is the least stable of
the periodontal tissues its structure is in a constant state of flux. The
;
physiologic liability of alveolar bone is maintained by a sensitive balance
between bone formation influences. 3one is resorbed in areas of pressure
and formed in areas of tension.
The cellular activity that affects the height contour and density of
alveolar bone is manifested by three areas4
i) .d!acent to the 1/ ii) In relation to the periosteum of the facial and
lingual plates and iii) along the endosteal surface of the marrow
spaces.
3) TOOTH EXTRACTION, WOUND HEALING AND FORMATION
OF THE RESIDUAL RIDGE
. specific feature of residual ridge formation is that its essential
components are formed as the conse7uences to healing of a significant bony
and mucosal wound created by tooth extraction. #istologic studies of
residual ridges indicate that extraction sockets heal with active synthesis of
trabecular bone. Trabecular bone formation reaches the edge of extraction
socket whereas the osteoclastic bone resorption takes place on the surface
of the residual ridge a combination of which results in a distinct porosity on
the crest of the residual ridge alveolar bone.
.aron and -herry described trabecular bone regeneration in the
sheep after locali6ed ablation. The radial arrangement of the developing
bone trabeculae observed in their defects resembled the radial trabecular
pattern observed on radiographs of healing tooth sockets coarse
birefingement collagen fibres formed a preliminary framework along which
the trabecular were oriented and were fabricated by fibroblasts marrow
reticular cells and osteoblasts. Trabeculae were absent where this
preliminary collagenous framework is failed to form. -ubse7uent
<
remodeling of the small primary trabeculae produced secondary trabeculae
that resembled the original cancellous bone pattern. The delayed tooth
socket healing often observed in poorly controlled diabetes inevitably
causes a poor alveolar ridge contour. . dense network of collage fibers
normal fills the socket soon after tooth extractions and the defect in diabetes
mellitus may be due to a reduced collagen production and an absence of
these fibers.
Precursor “template” collagen for bone wound healing:
The collagenous extraction socket matrix forms before bone
formation and it has been hypothesi6ed that this matrix serves as a template
or framework that orientates the forming bone trabeculae. )ontroversy
surrounds the nature of the collagen molecules that provide this template
function. #owever because of its potentials in guiding bone wound
healing the ma!or emphasis of current biologic studies of residual ridge
remodelling is directed toward the characteri6ation of this template stage of
bone remodelling.
. two stage process of bone formation is evident in endochondral
ossification in which cartilage tissue is initially present. )hondrocytes
undergo se7uential histo=differentiation which result in cellular
hypertrophy and apoptasis. The remnant hypertrophic cartilage matrix is
believed to provide the template scaffold for osteoblasts to precipitate bone
extracellular matrix. The template cartilage matrix is eventually resorbed
endochondral synchondrosis of the skull base and mandibular condyle.
*ne of the most obvious feature of the healing of tooth extraction
sockets is the absence of precursor cartilaginous tissue. This uni7ue feature
has been described by a general hypothesis that the tissue regeneration is
%
considered to be a reiterated process of tissue embryogenesis. In embryos
maxillofacial bone including tooth bearing alveolar process is formed
through intramembranous bone formation which is different from
endochondral ossification. In intramembraneous bone formation examined
in calvaria the intramembranous bone formation which is different from
endochondral ossification. In intramembranous bone formation examined in
calvaria the initial ectomesenchymal cells directly differentiate into
osteoblasts by passing the deposition and resorption of hypertrophic
cartilage matrix; osteoblasts can directly deposit osteoid tissue which is
then calcified.
It is of particular interest that recent investigations reported the
transient expression of cartilagenous precollagen type II m"+. during
intramembraneous bone formation type II collagen is a ma!or collagen type
of hyaline cartilage and thus has been long considered to contribute to the
structural integrity of cartilage tissues and provide a template during
endochondral ossification. The involvement of type II procollagen m"+.
in different tissues other than cartilage may suggest some as yet undefined
function of type II collagen unrelated to chondrogenesis.
In recent years type II collagen has been further investigated and its
two alternative splicing variants of type II. and type II3 are found to have
differing cell origins. Type II. is found in noncartilaginous tissues whereas
type II3 has a strong association with chondrocytes and cartilage tissue
formation. The expression of type II procollagen m"+. has been identified
in the healing extraction sockets in experimental animals by the method of
"+. transfer blot analysis and is situ hyridi6ation.
>
.nalysis of studies on the uncomplicated healing of extraction
wounds have shown that after the clot formation granulation tissue is
gradually replaced by connective tissues and later by intramembranous
bone without cartilage formation. . cluster of cells that are associated with
the early socket wound healing have been shown to express type II collagen
m"+.. . pu66ling finding is that investigators have failed to detect the
presence of protein collagen type II by way of immunohistochemical
studies in actively healing extraction sockets. This may be suggestive of
either lack of collagen type II translation or difficulties in detecting this
protein in the healing socket. -ome of the 7uestions that need to be
answered in the extraction socket of what are the role of these cells in the
socket healing if type II collagen protein is synthesi6ed. 'o systemic or
local factors influence the gene expression pattern during socket healing.
Two-stage process of bone formation:
)artilage collagen fibrils are composed of a group of different type
of collagen including type II. The surface of this fibril is associated with
small collagen type I?. 3ecause of the exposed perifibril location and the
interactive peptide structure of type I? collagen it has been postulated that
type I? collagen plays a molecular bridging role in the extracellular matrix
and contributes to formation of a cartilage tissue architecture.
It has been reported that collagen type I? m"+. is also expressed in
early hiealing stage of extraction sockets
@
,urther analysis of residual ridge remodeling in rats have revealed
that the α2 (I?) collagen m"+. which was expressed in the extraction
socket was different and markedly shorter than that of cartilage. The short
form of type I? collagen omits the multiple exons that encode the .mino
terminal globular domain (in above figure). Therefore this alternation
expression of the short form of type I? collagen which lacks the interactive
peptide structure may explain why cartilage tissue is not assumed in the
extraction socket. #owever the function of the short form of type Ix
collagen in residual ridge remodeling remains to be classified.
"ecent immunohistochemical data suggest that type I? collagen is
present only in the early bone formation stages of extraction socket healing
and seems to disappear during the maturation stages. It has been
characteri6ed in the similar transient expression of the short form of type I?
collagen along with type II collagen is embryonic chicken cornea in which
the principle orthogonal fiber architecture of the mature cornea is organi6ed
according to the template tissue primary cornea stroma. 3oth cornea and
bone posses the similar orthogonal pattern of collagen fibrils. The detailed
molecular assembly of type II and the short form of type I? collagen in
bone remodelling is not elucidated. #owever it is tempting to speculate that
the transient matrix containing short type I? collagen may be involved in a
tissue guiding role in alveolar bone repair as used in avian eye formation.
Transgenic and inactive gene allelic manipulation in experimental
animals:
To understand the role of a specific molecule one can generate
animals harboring an experimentally introduced mutation to the molecule or
inactivate the corresponding gene. -uch transgenic animals can provide a
powerful tool to investigate the conse7uences to the missing biologic role of
A
a specific molecule. -everal transgenic mice have been generated with
defective type II collagen. The introduced mutated pro α 2 (II) collagen
chains appears to be included in a procollagen molecule and prevent folding
into a stable triple helix. Transgenic mice with functionally impaired Type
II collagen result in chondrodysplasia into dwarfism short and thick limbs
a short snout a cranial bulge a cleft palate delayed minerali6ation of bone
and a severe retardation of growth for practically all bones. 3ecause type II
collage comprises the ma!or constituent of cartilage the principal
conse7uence of this mutation is anticipated to cause disorgani6ation of the
growth plate. #owever it is interesting to note that both endochondral
bones and intramembranous bones are affected by the Type II collagen
mutation.
Nakata reported the generation of transgenic mice harboring the
minigene of α2 (I?) collagen with an inframe delation of the central
domain. -ome homo6ygons transgenic mice displayed mild proportionate
dwarfism. The vertebral bodies were ovoid in shape as a result of a mild
ossification defect and the end plate in the mid=dorsal region were
irregular otherwise the offspring of the transgenic mice sunlived to their
maturity. .fter reaching maturity onset of osteoarthritic changes become
apparent particularly in the anterior part of the weight bearing areas of the
tibia. They reported that even before the histologic onset of osteoarthritis a
significant decrease in the intrinsic compressive stiffness was found in the
articular cartilage of the transgenic mice. ,urthermore corneas of the
transgenic offspring appeared opa7ue or irregular and were sometimes
infiltrated by capillary vessels. The opthalmopathy was found in about 2<B
of transgenic animals. These results strongly indicate that type I? collagen
2C
may play diverse biologic roles in various tissues including locali6ed bone
remodelling.
"ecently α2 (I?) collagen knock=out transgenic mice were
developed. The neogene was inserted in the exon @ of the α2 (I?) gene by
homologue recombinations which resulted in the total inactivation of α2
(I?) alleles including both premolars. Therefore this animal model allows
an investigation of the functional role of type I? collagen as a potent
element for alveolar bone regeneration. Dild type and homologous mutant
mice were analy6ed to elucidate the role of type I? collagen in residual
ridge remodelling. To evaluate alveolar bone repair the specimens were
obtained at > days and 2; days after tooth extraction. The extraction socket
of mice with inactivated α2 (I?) alleles indicated that there was a
considerable retardation in the formation of the trabecular bone pattern as
compared with the healing socket of the control genotypically normal mice.
The results indicated that the trabecular bone pattern was often disturbed in
Eknock=outF mice with some formation of cortical bone within the socket.
These data suggest that there may be two distinct bone remodelling
prcoesses. In the trabecular bone remodelling. The presence of type II and
I? collagen precursors seems to be necessary. In the cortical bone
remodelling type II and I? collagen precursors may not be prere7uisite.
-uccessful socket healing may use the former process which re7uire the
transient expression of template collagens including type II and I?.
) BONE REMODELLING PROCESS
5odelling is the correct word for the microscopic changes in the
bone morphology. "idge resorption is a misnomer because resorption is a
22
part of a process that leads to edentulous bone loss where atrophy implies a
passive process. Therefore the term remodelling is used to describe the
physiological process of bone loss. -ince in our topic were are including
even the pathologic process of the bone loss thus it would be apt to
consider it as residual ridge resorption.
"emodelling of bone involves three stages. This was put forth by
F!"#t and that has been elaborated on by several investigators since several
stage of cellular activity can be distinguished4
2. .ctivation phase.
$. "esorption phase.
9. ,ormation phase.
Activation : This is the first stage of remodeling persons which begins as a
result of specific local or systemic stimuli. It occurs at the microscopic level
on the surface of the lamellar bone. Dhether it could be cortical or
trabecular. .ctivation stimulation the rest of the resorption process. It
shows the migration of osteoclast precursors to an area of the bone surface
to be resorbed attachment of these precursor cells and subse7uent fusion of
these cells into multinuclear osteoclasts.
esorption 4 The resorption begins as the osteoclasts adhere to the bone
surface in response to the stimuli. These osteoclasts are probably derived
from the special circulating monocytes. "esorption may occur in the depth
of the haversian system of the compact bone or outside surface of the
trabecular bone. *ften this resorption occurs parallel to the stress placed to
bone and it influences the formation process. This process is followed by
the deposition and organic matrix which is responsible for stress resistance
of bone after calcification had occurred. "esorption also occurs in the
2$
absence of stress but it does so in a less organi6ed manner. This specific
factor responsible for resorption is yet to be determined. 3ut there is @=2C
days delay period. The resorbed surface is morphologically identified as
cement line.
!ormation phase 4 It is signalled by the local mesenchymal cells into
osteoclasts which concentrate or aggregate on the same surface and begin
to lay down the organic matrix.
There are skeletal envelops4
i) 1eriosteum ii) #aversian system iii) &ndosteum and iv) Trabecular
system
&ach of the skeletal envelops have characteristic bone balance which
is generally not 6ero.
'uring this stage osteoblasts differentiate at the sites previously
resorbed and start to deposit osteoid and bone on completion of the phase
the site enters a resting phase with no discernibe osteoid remaining
between the lining cells and the minerali6ed bone. Thus a close anatomic
and functional relationship exists between resorptive and formative cells at
discrete remodelling sites referred to as 3asic 5ulticellular (nit (35() of
bone remodelling. This is in all likelihood responsible for the
phenomenon that many treatment of metabolic bone disease developed to
inhibit resorption result in simultaneous inhibition of formation. +umerous
examples of this phenomenon exist and various schemes have been
devised to selectively affect then the resorptive phase or the formative
phase of the remodelling cycle. The rate of bone remodelling is determined
by the number of 35( operative at any given time. ,or the normal human
29
skeleton activation occurs about once every 2C seconds and the total
number of 35( in operation at any time has been estimated to be 9<
million remodelling is conceivably initiated at a particular site either by
mechanical triggers conveying some type of message to cells initiating
formation or resorption or by unknown sensory mechanisms that indicate to
the cells. The need to initiate a remodelling se7uence that bone in a certain
area has to be replaced.
$) HISTOLOGICAL OBSERVATION OF RESIDUAL RIGE
RESORBTION
The mandible and maxillary ridges differ in gross appearance from
other surface of the same bone. 0enerally the bone surface is smooth and
undulating and contains minute opening into the nutrient canals. ,oramina
are larger opening through which vessels and / or nerves of greater diameter
pass. 5ost foramina are well known anatomic entities. +either the foramina
nor the minute openings resemble the irregular defects present in the
residual alveolar ridge.
- The gross appearance of the defects ersembles cancellous bone. The
histologic sections confirmed the observation.
#istologically a well defined cortex with a lamelled surface was not
in evidence. /amellated surface had been resorbed and the #aversian
systems were undergoing resorption.
- "esorption was a constant factor. .n sections with defects showed
periosteal resorption. There was no evidence of repair. There were no
reversal lines in the sections. The resorption penetrated the bone marrow
spaces. The submucosa and periosteum invaded the bone marrow space
replacing the marrow with dense ).T.
2;
- It was observed histologically the mandibular ridge resorbs more
readily than the maxillary ridge. #owever the mandibular ridges
contained more supporting bone than did the maxillary ridges.
*bviously the supporting bone offered no resistance to the resorption.
- The resorption continued to expose the cancellous bone to the
periosteum Ca%&'()) reported that denture wearing patients
experienced more resorption of the alveolar process them did non
denture wearing sub!ects.
 A study was conducted in "#$%: To find out the histologic feature of
edentulous ridge. The ob!ective of the study was to observe the nature of the
edentulous ridge of sub!ects who were edentulous for varying time periods.
-ome of the sub!ects had worn denture while others had not.
)onnective tissue was studied in the ridge crest buccal and lingual
region. The feature observed were4
2. Thickness $. 'ensity 9. 1resence of inflammatory cells ;. 1resence of
an osteogenic periosteum.
&bservations:
2. The thickness of ).T. was found to be decreased from the normal in the
ridge crest region in both non denture and denture wearing groups. In
other regions (lingual and buccal) the thickness was considered normal
and no difference was noted between groups except for increased
thickness in the lingual region of the non dentuer wearing groups.
$. The density of connective tissue was increased in non=denture wearers.
3ut evenly divided between normal and increased in denture wearers.
2<
9. Inflammation in ).T. was slightly greater in denture wearers group. 3ut
was not a prominent findings.
;. Dhen any type of periosteum was present it was generally fibrous in
nature.
#ence we conclude that probable during healing process after
extraction of teeth the thickness of ridge ).T. is decreased while the
density is increased unrelated to the wearing of denture.
In brief the microscopic studies / histological revealed the following4
2. Garying degrees of keratini6ation acanthrosis thickness edema and
architectural pattern of epithelium in the same month and between
sub!ects.
$. Garying degrees of inflammatory cells from clinically normal to frankly
inflammed areas in both denture and nondentuer wearing patients.
9. /ymphocytes plasma cells mast cells and osteoclasts.
;. 'ense fibrous connective tissue (sometimes hyalini6ed) fre7uently
observed over crestal bone with fibers running parallel to epithelial
surface.
<. . vascular plexus outside the periosteum in areas of bone apposition.
%. -mall blood vessels in close contact with the bone margin in areas of
bone resorption sometimes in the lacunae with positive correlation
between the degree of inflammation vascular reactions and bone
resorption.
2%
>. 5arked diapharase activity in areas of bone remodelling either
formation or resorption.
@. .T phase activity in areas of bone formation and acid phosphatase
activity in areas of bone resorption.
A. The lack of evidence of bone resorption in areas which do not have
inflammatory cells.
2C. &ndosteal bone deposition reinforcing internal structure where external
surface has been affected by resorption.
22. /ack of periosteal lamellar bone on the external surface of the crest of
the ridge.
2$. . roughened crestal bone surface which is either actually resorbing or is
inactive but without versal lines on the external surface of the crestal
bone.
29. 'evelopment of secondary #aversian systems in remodelled compacted
endosteal bone.
2;. 5icroradiographic evidence of mandibular osteoporosis including
increased variation in the density of osteons increased number of
incompletely closed osteons increased endosteal porosity and increased
number of plugged osteons.
*) FACTORS AFFECTING RESIDUAL RIDGE RESORPTION
.s there is wide difference in the individual regarding the rate of the
residual ridge resorption. -ome patients show marked change where as
others minimal changes in the ridge form over a period of time.
2>
.ccording to the literature rate of bone loss is generally greatest
immediately following tooth extraction. 5andibular bone loss occurs at a
more rapid rate when compared to that of maxillary.
&pidemiologic studies are useful in trend finding investigations of
multifactorial diseases. It is entirely possible that """ is a multifactorial
diseases and that the rate of """ depends on one single factor but on the
concurrence of two or more factors which may be called +",a+t"!#. 5any
years ago it was suggested that for convenience possible factors could be
divided with four ma!or categories. This pattern of division was again
revered in 2AA@ by L(-)- .a/a%0(!- with few additions.
2. .natomic
$. 1rosthodontic.
9. 5etabolic.
;. ,unctional.
<. *thers.
"' Anatomic :
This includes 4 a) -i6e b) -hape c) ,orm d) -pace between ridges
e) 5uscle attachments f) .ction of tongue.
It is postulated that """ varies in the 7uality and 7uantity of the
bone of the residual ridges. It can be said that """ α anatomic factors.
It is the amount of bone which is regard to the time count of """. If
denser of bone slower is the resorption.
2@
.lthough 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.
(uality of bone 4 *n theoretic grounds if everything is normal. 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 is never
normal. &very patient is different especially in regard to the metabolic
factors.
)olf*s law
It postulates that all changes in function of bone are attended by
definite alteration in its internal structure and forces within the
physiological limits are beneficial in their massaging effect. *n the other
hand increased or instained pressure through its disturbance from the
circulatory system produces bone resorption. The amount and fre7uency of
stress and its distribution and direction are important factors in treatment
planning.
+' Prosthodontic factors
)linical observations indicate that excessive alveolar bone resorption
can be caused by physiologically intolerable forces produced by functioning
complete dentures.
The inherent denture factors which may affect the supporting
structures include4
i. The occlusal forms of the teeth.
2A
ii. The alignment of the denture teeth / occlusal pattern.
iii. 'eformation of the denture bases.
iv. 5aterials with which denture teeth are made and
v. The effects of the loss of proper occlusal vertical dimension (over
closure).
i) The occlusal forms 4 The form of the occlusal surfaces of artificial
teeth weather of the .natomic +on anatomic or C degree
configuration must have some effect on chewing efficiency and on
prices tending to distort the dentuer bases.
- *ne of the earliest opponents of the anatomic tooth form was F!(1+/
who coined the term Ecusp traumaF as one of the most serious defects
that had to be guarded against in complete denture construction. -oon
after S(a!2# developed his non anatomic tooth form which initiated the
introduction of many new designs to denture teeth throughout the years.
- .lthough disagreements continues to the advantages of one tooth form
over another. The sub!ect has been removed from the theoretical to a
more scientific level.
ii) )hewing efficiency 4 "esults of early studies on chewing efficiency
with various occlusal forms were contradictory. T/"%&#"1 a13
T!a&"44"1 a13 La44a!- found anatomic teeth to be more efficient
than non anatomic teeth whereas S"'"-k a13 Ma1)5 a13 V-1t"1
found no statistical difference between the efficiency of the anatomic
and non=anatomic teeth.
$C
5ore recent studies have shown that there is no statistical difference
in the chewing performance in denture teeth with cuspal ranging from C to
9C degree.
.side from studies of chewing efficiency using analysis of
masticated test foods the use of strain gauges attached to indication of
denture teeth and electromyography has been applied to this problem
H-+k(5 a13 A##" demonstrated that there was less activity from the closing
muscles when using anatomic (99 degree) teeth than when using <cm :
.natomic ($C degree) or non anatomic (C degree) teeth in tests of chewing
efficiency.
iii) &cclusal pattern : The arrangement of individual teeth in complete
dentures includes a myraid of possibilities ranging from a flat
occlusal plane with C degree teeth to a curved configuration which
allows anatomic teeth to guide and pass over each other in close
harmony with mandibular movements.
iv) ,enture base deformation : -tudies done by A#k(6 a13 H"5(!
showed that when the mandible with denture was pulled into lateral
and protrusive more deformation was caused under the denture with
anatomic tooth form than with non anatomic tooth form and same
was with acrylic resin denture bases which resorbed the ridge more
than the metal base when used with anatomic teeth than with non
anatomic teeth.
v) Tooth material : the material from which the denture teeth are made
may have some effect on the forces transmitted through the denture
base material to the supporting ridges.
$2
It is said that porcelain tooth when placed causes more resorbtion of
ridge than acrylic tooth.
vi) -oss of occlusal vertical dimension .over closure/ : The loss of
proper occlusal vertical dimension after the insertion of complete
dentures results in the triggering of a cyclic series of event
detrimental to the health of the residual alveolar ridges.
'enture EsettlingF is one of the most common terms associated with
complete denture prosthetics yet it has been excluded from prosthetic
glosseries and textbooks. This elusive term implies a sinking of the denture
bases into the supporting structures. M"#(# described EsettlingF as a
reorgani6ation of the osseous and mucosal elements underneath the denture
base.
5any authors have observed that overclosure causes the mandible to
be moved or rotated in an upward and forward direction causing occlusal
disharmony and excessive trauma to the anterior region.
-everal authors have presented detailed procedures for ad!usting the
occlusion to allow for a forward shift of the mandible during over closure
without occlusal interferences. The use of little or no vertical overlap in the
anterior denture teeth has been advocated by authors interested in
preventing trauma to the anterior areas of the mouth.
0' 1etabolic !actor and 2ystem
0eneral body metabolism is the net sum of all the building up
(anabolism) and the tearing down (catabolism) going in the body. In general
terms anabolism exceeds catabolism during growth and convalescence
levels off during most of adult life and is exceeded by catabolism during
$$
disease and senoscence. 3one has its own specific metabolism and
undergoes e7uivalent changes. .t no time during life is none static but
rather it is constantly rebuilding resorbing and remodelling sub!ect to
functional and metabolic stresses.
The four main levels of bone activity are 4 2) &7uilibrium $)
0rowth 9 ) .trophy resulting from decreased osteoblastic activity as in
osteoporosis and in disuse atrophy and ;) "esorption caused by increased
osteoclastic activity as in hyperparathyroidism and in pressure resorption.
3oth sides of the e7uilibrium must be known to understand bone
metabolism. The relative activity of both the osteoblasts and the osteoclasts
must be known. In e7uilibrium the two antogonistic actions are in balance.
In growth although resorption is constantly taking place in the remodelling
of the bones as they grow increased osteoblastic activity more than makes
up for the bone destruction. In osteoporosis osteoblasts are hyperactive
whereas in the resorption of hyperparathyroidism increased osteoblastic
activity is unable to keep up in the increased osteoclastic activity the
normal e7uilibrium may be upset and pathologic bone loss may occur. If
either bone resorption is increased or bone formation is decreased or if both
occur.
-ince bone metabolism is dependent on cell metabolism anything
that influences cell metabolism and specifically the metabolism of
osteoblasts and osteoclasts is of cells in general and hence the activity of
both the osteoblasts and the osteoclasts. 1arathyroid of hormone influences
the excretion of phosphorous in the kidney and also directly influences
osteoclasts the degree of absorption of calcium phosphate and proteins
determines the amount of building blocks available for the growth and
maintenance of bone.
$9
*ne of the most interesting metabolic phenomena concerns the
antagonistic effects of the E.ntianabolic #ormonesF (the adrenal
glucocorticid hormones including cortison and hydrocortisone). .ccording
to R(-,(1#t(-1 in the young person there is a relative predominance of
anabolic hormones resulting in continued growth and maturation of the
skeleton he further states as people get older especially women past the
menopause the anabolic hormones are so reduced that the antianabolic
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.
2ystemic !actors
The influence of these factors can be explained on the statement
given by G)-+k%a1. EThe status of bone e7uilibrium is variable depending
on the physiologic and pathologic process of the entire body for its
regulation whereas the results of systems disturbance the microscopic
e7uilibrium is shifted in favour of bone resorption a similar condition
prevails in alveolar bone loss of alveolar bone occurs regardless of the
condition of gingival tissue or the structural details of prosthetic applianceF.
3ormone : The three main principal hormones that regulate the plasma
concentration of calcium are4
2. "4+5 dihydroxy cholicalciferol 4 This is a steroid hormone formed
from vit. ' by successive hydroxylation in the liver and the kidney.
Its primary action is to increase the calcium absorption from the
intestine and mobili6e this ion from the bone and increase the
absorption from the kidney by approximately ACB.
$;
$. 3ypophosphatemia 4 -ince low phosphorous concentration in the
incubation medium of bone culture also has been found to enhance
bone resorption; these effects of hypophosphatemia may represent a
direct effect of serum phosphorous on bone to enhance bone
resorption. "ecently however it has been show that
hypophosphatemia enhances the synthesis of 2.$<
dihydroxycholicaliferol which is the active metabolite of vit. ' and
which has been shown to stimulate bone resorption. Thus it is
possible that the increased resorption seen in person with
hypophosphatema is in past of the result of excess 2$<
dihydroxycholicalciferol. In any case it is clear that
hypophosphatemia mediates directly or indirectly a marked increase
in bone resorption. 5oreover in experimental animals suggest that
normal levels of serum phosphorous influence the basal level of bone
resorption through further work is re7uired to be certain of the point.
In addition to these results in experimental animals it was found be
means of certain studies that hypophosphatemia in a human sub!ect
was associated with increased boner resorption. -ince phosphorous
is ubi7uitous in nature hypophosphatemia rarely if ever occurs as a
result of a deficiency of phosphorous intake. #ypophosphatemia
may occur in patients with duodenal ulcers who are treated with
antacids containing aluminium hydroxide gel which binds
phosphorous and renders it unabsorbable varying degree of
hypophosphatemia are also seen in patients with impaired of renal
tubular resorption of phosphorus although we would expect
hypophosphatamia of either glot or renal origin to result in increased
resorption further clinical studies will be necessary to settle this
issue. This can be included in bone loss due to increased resorption.
$<
Pa!at/5!"-3 H"!%"1(
3asic research is not definite in disclosing the exact mechanism by
which the parathyroid hormone regulates the calcium=phosphorous balance
in the blood. The chief argument at present is whether the hormone acts as a
direct control on the apposition and resorption of bone or primarily on the
kidneys by influencing calcium resorption by the tubules. Dhen the
parathyroid hormone is in!ected (hypoparathyroidism) there is an
immediate rise in the renal excretion of phosphate. This disturbs the blood
ca=phosphorous ratio by raising the blood serum calcium level. Then
phosphates are called from the bone bank by osteoclastic activity.
The parathyroid hormone has another function of maintaining the
blood level of the calcium ion the calcification of bone tissue will be
retarded to pressure the blood level of the calcium ion. This is related to the
action of vit. ' in an antagonistic manner. 1arathormone maintains blood
calcium by mobili6ing it from the bones by osteoclastic activity. Git. '
maintains blood calcium by increasing the absorption of calcium from
dietary source in the intestinal tract.
*ne of the most important systemic factors influencing the rate of
osteoclastic bone resorption is parathyroid hormone (1T#). (nder normal
conditions 1T# secretion is controlled by serum calcium concentrations
through a negative feedback mechanism. . slight decrease in serum
calcium concentrations as for example during the night when little calcium
is being obsorbed from the gut stimulates the parathyroid glands to secrete
1T# which in turn stimulates bone resorption then by delivery more
calcium to the extracellular fluid and closing the feedback loop.
The cause of high 1T# secretion can be divided into two categories4
$%
2. 1rimary hyper parathyroidism.
$. -econdary hypoparathyroidism.
Dhich occurs in a number of different clinical settings. #igh 1T#
stimulates bone resorption and there by causes bone loss. In primary hyper
parathyroidism the function of the parathyroid glands is abnormal in that
an abnormally large amount of hormone is secreted and as a result bone
resorption is increased.
In secondary hyperparathyroidism there is no abnormality in the
parathyroid glands the excess 1T# secretion is secondary to a fall in serum
calcium concentration and represents an attempt to return the serum calcium
to normal. . fall in serum calcium may be due 4 2) Too little )a being
absorbed from the gut $) Too much calcium being excreted in the urine
and 9) )alcium being lost from extracellular fluid to fetus during the third
trimester of pregnancy.
In all of these causes of secondary hyperparathyroidism. The
parathyroids attempt to maintain serum calcium at the expense of bone
calcium. 'ecreased external calcium absorption may result from
2) Inade7uate calcium intake $) small bowel disease such as sprue in
which there is impairment of the absorptive process 9) liver disease which
may impair fat absorption and thereby promote formation of insoluble
calcium soaps ;) 1artial gastrectomy which decreases calcium absorption
as a result of poor mixing of small bovel contents and by other mechanism
and <) . deficiency of vit. ' which may result from poor fat absorption.
$>
6strogen and ogen ,eficiencies
In general the sex hormones (.ndrogenes and estrogens) promote a
protein anabolic action on all tissues including bone. . striking storage of
nitrogen and calcium occurred in individuals with postmenopausal of serile
osteoporosis in one study when these hormones one administered. 5ore
than half of the women over <C years of age showed "oentgenographic
evidence of diminishing bone mass in a study by A)'!-0/t a13 R(-1,(#t(-1.
1ostmenopausal osteoporosis is the most common form of this
condition the aging person produces less and less of the .ndrogens and
ostrogens which results in faulty protein metabolism for tissue repair.
In estrogen deficiency the bone loss is not uniform the amount of
cortical bone does not decrease significantly whereas the amount of
cancellous bone in the metaphysis of the long bone decrease dramatically
the information available to date thus suggests that with regard to bone
resorption estrogen deficiency in vivo increase osteoclast numbers. 1arallel
with an increase in 35(8s. The increase in osteoclast numbers occurs
primarily on endosteal cancellous bone surface and estrogen treatment
reverses this effect. &strogen treatment of estrogen=deficient post=
menopausal women does not change the average depth of the osteoclastic
resorption lacunae which suggests that the resorptive activity of individual
osteoclasts is not affected by estrogen.
&steoporosis 7
*steoporosis is due to insufficient formation of the organic matrix.
This condition is fundamentally a disturbance of protein metabolism and
involves vitamins hormone and nutritional factors. This condition is
$@
usually found in edentulous patient. The clinical and pathophysiologic
viscos of osteoporosis has been refined recently to the concept of type I and
type II osteoporosis. Type I osteoporosis is defined as the specific
conse7uence of menopausal estrogen deprivation and characteristically
presents the bone mass loss notably in the trabecular bone. Type II
osteoporosis reflects a composite of age related changes in intestinal renal
and hormonal function. 3oth cortical and trabecular bone are affected in
type II osteoporosis. In either case one of clinical manifestations of
osteoporosis is observed as less radiographic bone density. The maxillary
residual ridge was reported to be significantly smaller in postmenopausal
osteoporotic women while their edentulous mandible remained the same as
the age=matched controls. . knife edged ridge is formed when bone
resorption occurs at the labial and lingual surface of the residual ridge in
preference to the occlusal surface. 1ostmenopausal women with lower bone
densitometeric scores exhibited a tendency to develop a knife edge ridge in
the mandible.
8slands of langerhans
The failure of these glands to produce sufficient insulin for the
proper utili6ation of glucose causes diabetes mellitus the high blood sugar
with the spillover into the urine is well known. The syndrome of poor
healing low tissue tolerance and rapid resorption of bone associated with
the diabetic patient is recogni6ed but the intrinsic causative factors are not.
The explanation for this syndrome is that in the absence of insulin a
relative nitrogen starvation amina acids being divested from protein
synthesis. . diabetic controlled by either insulin or diet is not affected by
this mechanism. #owever perfect control is rarely possible. Therefore a
$A
word of caution and explanation to diabetic patients is necessary so that
they can appreciate their prosthetic difficulties.
M-1"! a,,(+t ", "t/(! /"!%"1(#
Thyroid hormones 4 The thyroid glands are responsible for the regulation of
the rate of metabolism. #yperthyroidism increases the metabolic rate so that
a negative nitrogen balance results. -uch a balance is e7uivalent to protein
deficiency which can be a direct cause of osteoporosis. Thyroxine also has
a direct influence on the kidneys causing an increased excretion of )a and
phosphorous. This depletion of )a and phosphorous results in decreased
bone apposition and increased osteoclastic activity to marshal these
elements from the bone to compensate for their depletion.
9rowth hormone : Increases calcium excretion in urine but also increases
the absorption from the intestine. This effect may be greater than the effect
of excretion with positive calcium balance.
2ex 4 Domen have less bone mass when compared to men.
Age 4 .s the age advances there is decreased bone formation and increased
resorption.
2uprarenal glands 4 The adrenal cortex produces steroid hormones called
corticoids. *ne of these cortison retards osteogenesis. It was shown
experimentally that administration of .)TII interfered with the healing of
bone in rachitic rats whose treatment consisted of administration of )a and
Git. ' cortisone and related steroids are antianabolic may induce the
formation of glucose from noncarbohydrates and may increase the calcium
loss by direct affect on calcium excretion. The prolonged use and
9C
administration of such steroids are considered very dangerous to bone
tissue.
!unctional 4 when force within certain physiologic limits is applied to
living bone that force whether compressive 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 fre7uency intensity duration and direction of force are somehow
translated into biologic cell activity. In as much as the end result is brought
about by cell activity the metabolic factors are important. #owever in that
cell activity is influenced by force the functional factors are also important.
E7a1# stresses that mechanical factors constitute !ust one of several types
of factors that operate in the development and maintenance of the normal
for and si6e of bone. H(11(%a1 a13 Wa))a+/ considered 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.
,orce is applied through the teeth to the periodontal 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
Tra!ectories and it is generally felt that the trabecular structure confirms in
patterns to these tra!ectories.
The normal forces to the bone are removed along with their resultant
tra!ectories when the teeth are removed. #ence it is to be expected that
remodeling of bone will take place when the teeth are removed. N(8,()3
found in edentulous patients as compared with dentulous patients that the
trabecular wire finer and the cortex thinner with the cortex over the crest of
92
the ridge being incomplete in all patients and the over all si6e 7uite possibly
smaller. N(8,()3 also found that instead of the usual tra!ectories present in
the dentulous mandible the trabecular pattern in the edentulous mandible
was in general random except that in some specimens the trabecular near
the crest of the ridge were somewhat perpendicular suggesting the
development of tra!ectories to the compressive force of a denture.
Dhen are the functional factors of fre7uency intensity duration and
direction physiologic and when are they pathologicH Dhere is the dividing
line between stimulation and trauma or between disuse and useH The
dividing line is not the same for all patients. Dhat to one patient is
stimulation conducive to bone formation could well be trauma to another
patient resulting in bone resorption. The functional factors must be
interpreted in con!unction with the metabolic and anatomic factors.
'isuse atrophy and fracture are example of extremes of functional
force.
,isuse Atrophy 4 the use of natural teeth transmits stresses to the supporting
alveolar process within a certain range this is physiologically helpful
serving to increase the density and strength of the alveolar process.
#owever pressure exerted on a tooth which is out a line in the dental arch
causes traumatic forces to be transmitted to the supporting process. In this
situation resorption and reduced density of structure are observed in the
bone with eventual loosening and loss of the involved teeth.
Dhen natural teeth have lost and no stimulation is provided in the
residual ridge by means of a prosthodontic restoration the alveolar process
will be lost through disuse.
9$
. large protein deficit followed by metabolic derangements develops
from disuse. The deficiency is in the formation of the new protein matrix
with no disturbance of calcification.
. loss of closing free develops because the mucous membrane and
the periosteum cannot endure the force once received by the teeth this loss
of internal stimuli and the reduction of closing force are signals for disuse
atrophy and a remodeling of the bone in accordance with Dolf8s law of
Transformation. .s Dolf8s law states briefly that change in room follows
change in function and that its change is due to alteration of its internal
architecture and external confirmation in accordance with mathematical
laws.
'isuse atrophy does not result from the direct loss of nonfunctional
bone but rather from the lack of replacement of bone not needed for
function. -ome stimuli are present from the action of the denture. 3ut the
nature of the stimuli is not normal the response of the bone varies with the
degree the internal and the tissue tolerance to the stimulation.
eaction of :one to pressure and tension 4 .n increase of pressure within
the limits of tolerance leads to bone apposition. .s long as pressure does
not interfere with the normal blood supply nerve supply and drainage of
the bone tissues. The pressure is resisted. #owever whenever pressure
interferes with the blood or nerve supply or with the venous drainage of the
bone resorption invariably occurs. +ormally the stress of pressure and
tension on bone is transmitted through avascular tissue such as the teeth the
condylar articulation the intervertebral disc and other !oints such structure
under pressure are covered by speciali6ed fibrous tissue fibrocartilage or
hyaline cartilage. If the pressure is against a vascular tissue covering of the
99
bone such as the periosteum the blood supply to the bone is aggravated and
it is a target for resorption. The denture bearing bone has a complex blood
supply from two sources the main supply is internal from the interdental
arteries that pass through canals in the interalveolar septa. .fter extraction
if bone loss that slight the blood supply is not greatly disturbed. #owever
if extensive surgical procedure removed large amounts of alveolar bone.
The internal blood supply can be vastly altered by the bone callus. The
other blood supply comes externally from the periosteum. .rteries from the
periosteal network enter the bone as arterioles in the numerous Golkman
canals which open from the outer surface of compact prone.
Interference with the blood supply leads to bone necrosis the
interference may be due to pressure directly from the bone or it may be of
inflammatory origin. If inflammation is present a constant internal capillary
pressure acts to setup resorptive process. The amount of blood supplied to
the prone from within (intrinsic and surgical se7uelae) and from without
(periosteal network and denture base) can predispose little or great change
in bone form.
It is tempting to draw definite conclusions about this concept but it
needs further investigation. #owever it does seem to offer a logical
explanation as to why some patients exhibit so little bone loss and some
great loss in a given space of time.
OTHERS
,ietary !actors 4 'uring edentulousness the nutritional re7uirement are not
met with proper attention there will deficiency of the same and this will
affect the residual ridge resorption. This usually happens because of
impaired masticatory efficiency and to complicate further the alveolar bone
9;
is over loaded by complete denture where forces generated are transmitted
directly to alveolar prone.
,ood are classified as a) 1rotein b) )arbohydrates c) ,ats
d) Inorganic elements and e) Gitamins.
Protein 4 1rotein is necessary to build and maintain tissue and to supply
energy. The necessary daily about re7uirement of protein is approximately
9 ounce. .ged persons need more than the minimum amount of protein for
the maintenance of tissue health.
;arbohydrate 4 They provide the chief source of energy. They are related
only indirectly to bone resorption though association with diabetes and by
substitution for more favourable foods.
!at 4 ,ats are organic substance that yield heat and energy and only
secondarily build up repair tissue.
Vitamins 4 'iet must contain vitamins for development growth and
function of the body.
Vit' A .;arotene/ 4 'eficiency of this causes renal damage by hornification
of the tubules. This damage results in the abnormal loss of phosphorous and
the tubules lose the capacity for reabsorption. The imbalance of the )a=
phosphorous ratio leads to osteoporosis.
. lowering of Git. . also has an effect on the osteoblasts so that they
engage in disorderly and uncontrolled activity. The cells ad!acent to the
bone modulate to osteoclasts and become active.
9<
There is a damage of #yper vitaminosis . but experiments are
inconclusive as to the mechanism. -ome reports indicate an acceleration of
matrix remodeling while others seem to conclude that excess vit. .
accelerate the activity of the osteoclasts. The general function of Git. . in
regard to bone is its influence on the activity and position of the osteoblasts
and osteoclasts.
Vit' : ;omplex 4 Git. 3 complex produces effects in bone similar to a
protein deficiency C/a#( reported degeneration of bone enamel and dentin
in rats on a 3=complex deficiency diet. *steoporosis of gingival
inflammation were reduced in dogs by withdrawal of nicotinic acid. This
condition was corrected by addition of this part of the 3=complex to diet.
Vit' ; 4 The collagen content of prone is reduced in vit. ) deficiency the
lossening of teeth in survey is due both to prone resorption end to
disorgani6ation of the periodontal fibres and members the periosteum is
affected in a similar way. It thickens and the cells appear immative and
resemble fibroblasts. This condition may make the periosteum more easily
in!ured by the denture base sot that inflammatory process are triggered by
the denture base at lower pressure levels.
Vit' , 4 'eficiencies of Git. ' disturb the )a=phosphorous balance and
promote prone resorption.
3abits 4 #abits such as food intake masticatory bruxism sleepswith
denture holds pipe sucks fingers bites nails nibbles with anterior teeth etc.
can affect """.
:iological factors 4 such as tissue health saliva content oral hygiene oral
bacterial flora drug or alcohol intake.
9%
DIAGNOSTIC AIDS TO DETECT RRR
5any techni7ues have been used to establish that bone is in fact
being turned over.
2. adiographic 4 This procedure is widely used to detect bone
resorption and formation phenomenone by taking periodic
radiographs.
$. Tetracycline labeling : In this tetracycline is in!ected into the body
through oral or pariental administration and should be repeated the
same after every week for < 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 because the resultant tetracycline
calcium chilate formed is fluoroscent and can be viewed by
fluorescence microscopy.
9. 1ercury porosimetry 4 *steocytes are also capable of bone
resorption (i.e. periosteocytic lacunar bone resorption). This is
evaluated by enlargement of osteocyte lacunae. Therefore inorder to
determine the 7uantitative importance of osteocytic resorption. .
method known as 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. -ince 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 7uantitate osteocyte lacunae canalicular volume which
9>
enlarges as a result of osteoclastic resorption and vascular canal
volume which enlarges as a result of osteoclastic resorption.
PATTERN OF BONE RESORPTION AND ANATOMICAL
CONSIDERATION
0ross anatomic studies of !aw bones have revealed a wide variety of
shapes and si6es of residual ridges. In order to provide a simplified method
of categori6ing the most common residual ridge configuration. It has been
described as a system of % patterns of residual ridge forms have been
described.
*rder I : 1re extraction
*rder II : 1ost extraction
*rder III : #igh well rounded.
*rder IG : Inife edge
*rder G : /ow well rounded
*rder GI : 'epressed or invested
&ven among individuals of the same sex there exist large variations
in the morphologic characteristics of the residual ridge and associated
bones and these can be related to their original anatomic features. There are
however certain patterns of resorption and some persistant anatomic
structures that can be recogni6ed from one case to another. These structures
are palpable when they become protruberant they are the genial tubercles
the external obli7ue line and the mylohyoid crest for the mandible or for the
maxilla the nasal spine and the pterygoid plates.
The usual changes that take place after dental extraction are those of
a ridge initially wide enough at the crest to accommodate the natural teeth
9@
that changes to one that is narrow and sharp then=flat and finally concave.
These four stages of resorption correspond to the classification of residual
ridges unable to ade7uately maintain denture in place.
0roup I 4 #igh crestal muscles over non=resorbed ridge
0roup II 4 -harp atrophic residual ridge.
0roup III 4 .bsence of residual ridge and resorption to the level of the basal
bone.
0roup IG 4 .bsence of residual ridge and part of the basal bone.
1andibular changes :
In the anterior region one can observed progressive deterioration of
the lateral bone profile the angulation of the anterior slope and the ridge
form the profile is modified from a pear=shaped appearance to a pointed
one. -oon after teeth are extracted the anterior slop angulation gradually
loses its perpendicular position with the mandibular plane as the crest of the
ridge moves backward the ridge leads to a flat and round basal bone shape
and more rarely to a concave form where the basal bone itself is involved.
In the premolar molar region bone loss is more rapid than anteriorly
because of the resorptive nature of the posterior dorsum and a lower
position of reversal lines. #ence bone resorption of the basal bone is more
fre7uent in this region. Typical patterns of resorption are recogni6ed and
outlined by the presence of this structure that resist resorption the external
obli7ue line and the mylohyoid crest the concavities seen from the different
planes may be present; a lateral dishing of the crest from the cuspid to the
retromolar region and a longitudinal midbody concavity.
9A
The dishing of the crest is best revealed by the lateral cephalogram.
In more advanced stages of atrophy these posterior bilateral concavities are
more pronounced with erosion of the basal bone they may become
associated with a roundly shaped anterior basal bone a fre7uent finding
described as the sphenoid anteriors basal bone with posterior concavities.
*n the medial side of the residual ridge the bone contour forms a gradual
slope toward the mylohyoid crest. In very advanced stages the concavity
occupies the ma!or portion of the dorsum of the corpus. It is more
commonly located between the dense external obli7ue line and the
mylohyoid crest.
The position of the teeth in the alveolar basal bone complex may also
play a role in these changes the lingual inclination of the molars and the
more facial position of the premolars canine and incisors which result in
the presence of more bone on the lingual side of their roots. )ontribute to
the fre7uent occurrence in resorbed mandibles of another structures the
paralingual crest. This palpable crest originating at the myolohyoid crest
itself extending anteiorly in a downward direction may become a true
lingual shelf. It may fuse with another structure that becomes protuberant
and palpable in advanced stages of atrophy4 the genial tubercles.
,our stages of ridge resorption and classification of deficient residual
ridges4
;C
1axillary changes 4 1atterns of resorption in the maxilla differ from those
in the mandible. 5axillary ridge resorbs usually more evenly than the
mandibular ones because of larger denture bearing areas with the palate
providing a more e7ual distribution of mechanical forces. Dhen the anterior
maxillary bone disappears at a faster rate than the posterior part it is more
often due to excessive forces originating from natural mandibular incisors
and inade7uate posterior prosthetic support.
The lateral cephalogram uncovers an anterior maxillary slope that
represents the external side of the triangle formed by the meeting of the
palate with the anterior ridge. The angulation of this slope relative to the
palatal plane persists much longer throughout the different stages of atrophy
than in the opposing !aw. This particularly could be explained by the natural
protrusion of the anterior maxilla which is designed to hold incisors that
are normally inclined at 22C degrees with the palatal plane. .fter dental
extraction and during ridge remodeling the posterior drift of the anterior
crest does not become as pronounced as in the mandible because of this
advantageous bony artchitecture. .n anterior ridge form persists for a
longer period time the angulation of the slope is affected only in advanced
stages of atrophy when the triangular form disappears and the crest reaches
the same level of the palatal bone or even below this level. In these
instances there is pro!ection of the nasal spine.
;2
"esidual anterior maxillary triangle and persistence of ori anterior
bone contour slope throughout different stages of atrophy
In the posterior region progressive reduction of the width of the
maxilla takes place as the ridge resorbes. This process is related to the
outward inclination of the maxillary premolars and molars to accommodate
for the lingual angulation of the mandibular teeth and to the presence of
thin buccal plates more susceptible to resorption than the thicker palatal
ones. The pterygoid plates will become palpable in advanced stages of
atrophy their extremities being located below the palate.
8ntermaxillary changes
The relationship that existed between the two maxilla when teeth
were present might have undergone a change after ridge resorption with an
increase of interridge distance as the most obvious change in the vertical
bone especially in the anterior region.
-agittal and anteroposterior relationship are also affected. .n inverse
ridge relationship and a pseudo prognathic condition will develop with
advanced stages of atrophy. The maxillary ridge will be reduced in si6e
whereas the mandibular one will be expanded when ridge resorbtion
reaches the level of the basal bone. This transformation is favoured by the
natural architecture of both maxilla the circumference of the crest of the
maxilla being longer than the circumference at its base because of the
outward inclination of the teeth; the reverse is present in the mandible
where the teeth and their supporting tissues are seated over a wider bone
base.
;$
2oft tissue changes
-oft tissue changes also occur after teeth are lost and dentures are
worn. . crestal scar bond representing the remnants of the attached gingiva
is usually present all along the crest. It is more prominent and hyperplastic
when some residual ridge remains. It then acts as a protective cushion
between the sharp residual ridge and the denture base. #eavy fibrous tissue
will develop in the tuberosity regions especially when maxillary molars
were removed at an early age or when the maxillary denture was not
rebased in the first years after teeth were extracted. This tissue puts up the
space left by lost bone.
ANATOMICAL CONSIDERATION
5ental foramen becomes more close to the denture bearing areas the
alveolar process decreases in si6e the change of denture impingement on
the mental nerve increases with bone loss and the nerve is more vulnerable
to the in!ury during surgical grafting or implantation procedures.
1rogressive bone loss leaves the nerve near superior surface of the
mandible.
;9
The ultimate result of complete alveolar bone loss is concave
superior surface of the mandible. This concave surface represents the upper
surface of the cortical plate of the mandibular inferior border. In severe
cases the genion tubercles may be superior to the crest of the mandible
pressure on the mucosa on this area cause sharp pain.
5uscle attachments such as buccinator mentalis mylohyoid and
genioglossus do not migrate significantly """ leaves the muscle
attachments close to the crest of the ridge muscle function will often lift the
muscle and overlying mucosa above the level of the alveolar ridge thus
reducing the amount of the alveolar bone exposed in the mouth. .s the bone
loss progreses in the maxilla the palatal vault becomes relatively more
shallow and redundant soft tissues forms labial to the alveolar crest. The
nasopalatine neurovascular bundle may end up on the crest of the ridge or
anterior to it. Impingement on this nerve by the denture may occur.
#owever this is less often a problem when compared to the tough mental
nerve. The shape of the maxilla during """ is dictated by as many of the
factors as in the mandible. In case where lower anterior teeth occlude with
the upper complete denture. """ occurs in the anterior ridge where height
decreases to a point of dehiscence between the mouth and the nose. This
usually occurs at or !ust posterior to the piriform rim of the nose. The
anterior nasal spin may be almost with the level of the alveolar crest. """
in the anterior maxilla mostly occurs on the labial and inferior aspect of the
alveolar ridge so that the crest moves posteriorly. (pper lip support is
progressively lost as anterior maxilla decreases in si6e. This combined with
the relative anterior movement of the mandibular ridge results in an
increasingly )lass III facial form and ridge relationship.
;;
1osteriorly as the maxillary tuberosity decrease in height it
approaches the level of the mucosa that is draped from the muco=gingiva
!unction on the posterior aspect of the maxillary tuberosity i.e. hamulus.
This change oblitrate the posterior slope of the tuberosity. .s the mandible
becomes smaller as the teeth removed resistance to the fracture is reduced.
,racture in extremely small edentulous mandibles are especially omnions
because of the lack of bone mass for fixation and due to the changes in
blood supply. .s """ occurs ma!or source of blood supply to the
mandible change from centrifugal to centripetal (periosteal) the inferior
alveolar vessels become smaller and less significant in the nourishment of
the mandible. Therefore the surgical procedure that elevate the mandibular
periosteum compromise the blood supply more as the mandible becomes
smaller.
CLINICAL SIGNIFICANCE
)linical observations indicate that excessive alveolar bone resorption
can be caused by physiologically intolerable forces produced by functioning
complete dentures.
)hanges which have to be considered and taken care while
fabricating the complete denture can be grouped into five ma!or categories.
These are4
2) .ppearance (facial and teeth).
$) &fficiency of mastication.
9) 1honetics.
;) 1ain and discomfort (.lleviated or initiated imaginary or real) and
<) 1rone and tissue changes.
;<
Appearance
)ommonly seen men are taller have greater facial heights and !ust
more !aw bone to resorb after dental extraction. The ratio of potential units
of bone to resorb to the years of resorption acts in their favour.
3ut one should not assume. #owever that men have an advantages
in treatment over women because men usually have more bone left after the
same number of years of denture wear. +ot only the volume of bone but
also its form must be examined. . large residual basal bone does not
necessarily means a more favourable ridge for denture construction or one
superior to a but for the convenience of understanding and implementing
certain parameters so that the proper care is taken for the prevention of the
further residual bone resorbtion. Thus following 'evan8s scientific words.
Its perpetual preservation of what remains of the oral masticatory apparatus
rather than a meticulous restoration of what is missing.
De start with clinical consideration for """ from impression
procedure
I%&!(##-"1 P!"+(38!(#
3efore impression procedure care has to be taken on selection of
custom made trays.
- If the tray selected is too large it will distort the tissue around the
borders of the impression away from the bone.
- If it is too small the border tissues will collapse inward onto the
residual ridge. This will reduce the support for the denture and prevent
the proper support of the lips by the denture flange.
;%
- .s we are know the commonly used two procedures for the final
impression procedure are4
2. 5inimal pressure techni7ue.
$. -elective pressure techni7ue.
2. The minimal pressure techni7ue with mucostatic principles ignores
the value of dissipating masticatory forces over the largest possible
basal seat=area. If for example the patient could develop masticatory
force of 9Clb it is evident that the larger the basal seat area the less
force would be exerted on each s7uare millimeter of underlying
mucosa furthermore the form of the mucostatic denture minimi6es
the retentive role of the musculature. Today a large proportion of
dentists make impressions with minimal pressure in order to avoid
distortion of the mucosa and ridge areas which may undergo
considerable pressure otherwise.
$. The principle of this procedure making impression is based on the
being that the mucosa over the ridge is best able to withstand
pressure as compared to the mucosa covering the midline is thin and
contains very little submucosal tissue. 5any fine dentures are made
according to this principle of selective pressure and definitive
!udgement on the merits of this approach must be deferred. It must
be emphasi6ed however that this techni7ue demands firm healthy
mucosal covering over the ridge.
- If flabby ridges exist than decision to make mucostatic functional or
selective pressure all have to be considered. It can be argued that tissue
tissue will become displaced in occlusal function and therefore should
;>
be improved in a functional state. #owever as with all functional
impression techni7ues the amount of functional placement is unknown
the functional movement probably would not be the same in extent or
direction with each functional load because the patient is more often at
rest than in occlusal function it is not practical to make the impression
of the tissue in a functional state.
- The true mucostatic theory as it relates to impression making may find
advocates who are dealing with the hypermobile ridge crest. The
principle of pareals law as related by 1age. #owever would have
7uestionable value here because the excessive tissue movement
encourages denture base movement. This will prevent the e7ual
distribution of force that the true mucostatic principle purposes.
9. The use of a combined mucostatic and functional impression
techni7ue the selective pressure impression techni7ue seems to be
the most advantageous for the hypermobile ridge crest as with most
complete denture impressions the hypermobile tissue itself would be
recorded at rest with functional placement of border tissue to
enhances denture retention and stability. 5any techni7ues have been
proposed depending upon the severity of the redundancy and it is
not the intent to suggest a specific impression techni7ue here
<aw relation
)orrect recording of vertical and hori6ontal relations are e7ually
important for the preservation of residual bone resorption.
In hori6ontal relations unless centric relation is established properly
the mandibular teeth will not occlude properly with those on the maxillary
;@
arch thus proper occlusion is essential to the health of bony support.
*therwise during eccentric movement it causes pressure on bone due to
failure of the factor stability. #ence cause resorption of bone.
- /oss of occlusal vertical dimension : the loss of proper occlusal vertical
dimension after the insertion of complete dentures result on the
triggering of a cyclic series of events detrimental to the health of the
residual alveolar ridges.
- 'ue to excessive interarch distance because premature striking of teeth
cause recurring trauma to the tissue (i.e. bone and mucosa) and longer
leverage making the denture more outward to manipulate and more
easily displaced.
- Dhenever an excessive amount of bone has been lost from various
causes (sch as periodontal disease ill fitting denture that have been worn
for many years partially edentulous months especially with all the
mandibular posterior teeth gone) it is possible to reduce the denture
space an undesirable amount.
- In narrower knife=edged ridges that cannot be made comfortable in any
other manner may be treated by reducing the occlusal vertical dimension
to trauma and sorners.
S()(+t-"1 a13 A!!a10(%(1t ", t((t/ 9
&cclusal form : The form of the occlusal surfaces of artificial teeth
whether of anatomic non anatomic or C degree configuration must have
some effect on chewing efficiency and force tending to affect the
underlying tissues.
;A
The arrangement of individual teeth in complete denture include a
myriad of possibilities ranging from a flat occlusal plane with C degree teeth
to a curved configuration which allows anatomic teeth to glide and pass
over each other in close harmony with mandibular movements. .dvocates
of cuspless flat plane occlusion reverse pitch occlusion and variations of
the reverse pitch occlusion i.e. (pleasure curve) consider such occlusal
schemes to be effective in helping to preserve the underlying ridges.
1roponents of anatomic teeth for complete dentures emphasi6e
careful settling and selective grinding of the teeth to minimi6e lateral
stresses and the resulting tissue trauma.
1lacement of the posterior teeth. This factor also plays an important
role while arranging the posterior teeth. It is said that by placing the
posterior teeth on the crest of the ridge the stress distribution is e7ually
distributed and reduces the bone resorption. -pecial attention has to be
given in patient suffering from diabetes or the above mentioned systemic
diseases.
Tooth material : .s it is said the material from which the denture teeth are
made may have some effect on the forces transmitted through the denture
base material to the supporting ridges.
Dhile a complete denture is given against a natural dentition.
Ideally acrylic teeth are preferred as the porcelain are brittle material
causes attrition of the natural teeth and if porcelain teeth are used than the
occlusal surface have to be covered by gold to prevent much wear and tear.
. very dangerous and traumatic combination of teeth is acrylic resin
posterior teeth on one or both arches and upper and lower porcelain
<C
anteriors. 3ecause of the abrasion of the posterior teeth the anterior teeth
develop interfering contacts during mastication that will continually
traumatic the anterior part of the upper and lower denture foundation. This
is potentially dangerous to the health of the supportive tissues and should
always be considered when selecting the tooth materials.
2i=e of posterior teeth: the selection of the proper tooth si6e or mold is
based upon ' the capacity of the ridges to receive and resist the forces of
mastication and space available for the teeth and the esthetic re7uirements.
De considered is the first one. In most complete dentures the lower
ridge offers less support to the forces generated by the occlusal surface of
the teeth. Its smaller area of support and more rapid resorption pattern
progressively narrow and reduce the height of the lower ridge. 3ecause of
this the use of posterior teeth should favor the lower ridge. ,or these
reasons the determinants for selection will be based on the lower ridge.
Dhen the lower ridge is strong well formed and covered by a
generous area of attached masticatory (keratini6ed) mucosa the full space
available can be used because this ridge has the capacity to tolerate the
forces of mastication. Dhen the ridge is weak resorbed and covered by
only lining mucosa then the si6e of the posterior tooth should be smaller.
This will limit the occlusal surface which in turn will minimi6e the forces
directed to such a ridge.
The inverse ridge relationship that may result from severe loss of
bone will create problems in constructing the denture and placing teeth. In
order to use the buccal shelf a stable dentin bearing area the posterior
mandibular teeth must be placed closes to the vestibular side and the
maxillary teeth outside the ridge it one wishes to correct the crossbite
<2
relationship both dentures conse7uently will be mounted outside their
original bearing areas.
,entin base deformation : ,orces generated by reaction at the occlusal
surfaces of the denture teeth must be transmitted to the denture base
prior to the ultimate dissipation of these forces in the supporting
residual alveolar ridges.
,or degenerative denture ridge patients there are three types of
denture bases4
2. "esin base.
$. )ast metal base.
9. 1rocessed resilient lined denture bases.
-harry .show and #erper used strain sensitive lac7uer to study
deformation patterns in bone on skulls (with dentures) when the mandible
was pulled into lateral and protrusive positions. 5ore deformation was
caused under the dentures with anatomic tooth forms than with
nonanatomic forms.
-tudies employing electrical strain gauges embedded in various type
denture bases have been conducted to measure deformation occurred during
mastication with anatomic than with nonanatomic teeth and acrylic resin
denture bases deformed much more than did metal bases under similar
situations. *ne study demonstrated that reducing the occlusal surface area
had no significant effect on deformation whereas reduction of the cusp
angles significantly reduced the deformation of the mandibular denture
base.
<$
- .fter curing the dentures the lab remounting has to be done and
selective grinding for working balancing contacts and for protrusive
balance has to be carried out in order ot remove any interference.
- /astly after insertion of the denture the patients have to be recalled on a
regular schedule correct any existing occlusal disharmonies an
encouraging the patient to remove this dentures upon retiring.
1asticatory apparatus therapy
*lder edentulous patients fre7uently suffer from problems involving
the temporomandibular !oints and imbalance with spasms of the muscles of
mastication. These conditions should be treated alleviated and corrected if
possible before !aw recordings are attempted and new dentures constructed.
,ortunately this can accompany the tissue treatment.
Dhen these problems exist the old dentures are duplicated the
duplicated dentures are then lined with soft resin for impression purposes.
The soft lined dentures are then articulated with a face=bow and centric
relation records. The upper denture is converted via a laboratory duplicators
to a self curing resin base the occlusion is surveyed and if nearly correct
and with an acceptable vertical dimension the dentures are ground in to a
balanced occlusion. Dhen the occlusion is less than acceptable the lower
denture is removed from the cast and the lining removed the lower denture
is positioned into centric occlusion against the upper denture and luted to it
with sticky wax. The lower cast is lubricated soft lining resin is placed on
the basal surface of the lower denture the articulation is closed to a
predetermined vertical dimension and the resin is allowed to cure the sticky
was is removed the occlusion is checked and mucin imperfections are
eliminated. 3y this means the old lower dentures which has often moved
<9
forward into a prognathic relation with collapsed vertical dimension can be
corrected. In doing so we have supported the mandible and maxilla and
established a good centric occlusion and occlusal vertical dimension we
have relieved the strain on the musculature and the temporomandibular
!oints.
,or a short time there may be distress in the T5J or the
musculature this will cause some resolutions in the apparatus and a shift in
the occlusion with successive treatments the lower denture can again be
relieved and the repositioning process repeated progressively obtaining a
better centric relation record and desirable vertical dimension such
treatment may solve the emergency problem 7uickly while preparing the
patient for new denture.
SURGICAL TREATMENT CONSIDERATION
- (sually the problem associated with denture wearer is one bone loss
that affects ridge form and increases muscle interferences. 3efore
hydroxyapatite become available this loss could not be replaced except
in extreme atrophy when ridge augmentation with bone graft was used
with all the uncertainties of resorption and inade7uate gain of ridge
form.
- 1re prosthetic reconstructive surgery was limited mainly to ridge
extension procedures with muscle reattachment the outcome of this
surgery was dictated by the contour of the residual bone. These
procedures were very successful. If there was not atrophy such as in
group I patients or if the bone loss has affected more the width from the
height of the residual ridge such as in certain group II cases. 3ut when
very little ridge was left or when only the basal bone remained and the
<;
contour was deficient little gain could be expected from extension
techni7ues unless extensive detachment of the chin and tongue
musculature was done. #ydroxyapatite has opened up a new in
preprosthetic reconstructive surgery. It offers numerous possibilities.
This material not only can be used to reconstruct an ideal ridge form
with less relationships with the help of dependable techni7ues.
.lthough many patients with poor residual alveolar ridges wear
complete dentin successfully other experience varying degree of difficulty.
5ost patients complaints are related to the mandibular ). '. longitudinal
studies indicate that the bone loss associated with the mandible is four times
greater than that associated with maxilla. In extreme atrophy the mandibular
denture can impinge upon the contens of the mental foramen and / or the
inferior alveolar nerve and cause discomfort and parasthesia of the lip. .n
extremely atrophic mandible is also more susceptible to fracture. These
problems are especially significant in relatively young patients who can
expect to wear prosthesis for many more years.
- Those have been many attempts to mitigate the problem by various
materials of treatment that incluide4
2) -oft tissue vestibuloplasties to increases the relative height
and extent of the denture foundation.
$) -ubperiosteal or endosteal implants to improve comfort and
retention of the denture and preserve the remaining
mandibular bone.
<<
9) .ugmentations with alloplastic materials such as proplast
calcium aluminate ceramic material to increase the vertical
height of the mandible and.
;) .ugmentations with homogenous and autogenous bone and
cartilage in different forms and combinations to increase the
vertical height of the atrophic mandible.
- Tissue augmentations for atrophic mandibles may be divided into the
following categories4
2) Implantation of free6e : dried homogenous bone and cartilage.
$) Implantations of autogenous cancellous bone and /or particular to
marrow in con!unction with some form of tray.
9) Implantation of block sections of autogenous ilac crest or ribs
cortical and cancellous bone.
.ccording to the surgical procedures to be followed by the ""
according to "oger 5asella classified as4
9roup 8  3igh crestal muscles and non resorbed ridge:
'ifficulties in achieving stability and retention are not always related
to a deficit of bone. )ertain patients with ridges that have resorbed very
little especially the mandibular ridge cannot be helped a conventional
prosthodontic approach. The tonicity of the muscle and / or their
attachments at the crest of the ridge prevent the development of the
necessary extension of buccal and lingual flanges needed for stability and
retention. "idge extension procedure is vestibuloplasty may be benefit this
<%
group twice the anteriors slope of the mandible is favourable to again of
denture bearing area.
9roup 88 painful atrophic ridge
5ost of the problems incomplete denture prosthodontics are of this
type. (sually the ridge has resorbed until the crest made of sharp lingual or
palatal cortical plate covered by a redundant of tissue that moves with
palpation and is painful to pressure. 5any non surgical attempts at treating
the hyperplastic (flabby) ridge have been attempted they range from
mucostasis impression to the use of tissue conditioners. These procedures
have not only partial success since the mucoperiosteum of sharp bony
spicules remains.
9roup 888 > Absence of residual ridge :
5any patients with ridges that have been reduced to the basal bone
may have better masticatory function than those patients in the two previous
groups the mandibular denture rests on a painless flat or fre7uently serves
to stabili6e the denture may exist these patients with above average muscles
coordination and the capacity to provide the e7uilibrium of the orofacial
muscles necessary to retain the denture in place may benefit from the
refinement of excellent prosthodontic treatment using a conventional
approach. #owever for those group III patients with a severe functional
handicap a ridge augmentation with implements procedure should be
considered.
2. Vestibuloplasty 4 The literature is replete with various techni7ues for
vestibuloplasty. These range from the early techni7ue of ridge
extension with secondary epithelia6ation to techni7ues that
<>
emphasi6e to importance of including the attachments of the muscles
of the floor of the mouth in the dissection. The original description of
the total lowering of the floor of the mouth with vestibuloplasty and
split thickness skin graft was presented by *bwer6er in 2A%9 which
still serves as the standard approach.
(ntil the adherent of predictable implant treatment augmentation
procedure of the edentulous maxilla and mandible focused on
reconstruction of lost "." and archform for retention of conventional
dentures. Today our goals for augmentation and reconstruction have
broadened because implant utili6ation with its advantages of increased
support for function and bone preservation with time has become the
preferred endpoint of reconstruction the placement and growth of viable
healthy mature bone in areas of potential implant placement are now our
primary concerns. 0ood ridge form and / or soft tissue extensions are still
preferable but are not as critical if an ade7uate number of implants are
available to support prosthetic. 1reviously used large scale secondary soft
tissue procedures for improving the denture bearing area such as
reconstruction of the floor of the mouth and buccolabial vestibule
(vestibuloplasty) with split thickness skin grafting are loss fre7uently
necessary when implants are first soft tissue manipulates is addressed
relative to implant procedure and is usually more locali6ed with much less
patient morbidity implants have become or great step forward in our
progress in treating the edentulous maxilla mandible.
<@
1axillary augmentation for utili=ation of implants:
The severely resorbed maxilla re7uires bone grafting of the more
common techni7ues described for maxillary grafting that have been used
with success are4
2. )orticocancellous horseshoe graft obtained from the ilium and fixed
to the maxilla with osteointegrated implants.
$. /e,ort I down fracture with an interpositional cortico cancenllous
graft obtained from the ilium and placed into the antrum and anterior
nasal floor.
9. )orticancellous onlay block graft obtained from the ilum and fixed
to the remaining alveolar and / or maxillary sinus floor with wires or
screws.
;. 1articulate autogenous corticocancellous ilium (.)I) mixed with
porous hydroxyapatite (#.) particles and grafted in onlay fashion
and / or into the maxillary antral floor / sinus lift procedure.
1andibular augmentation
5andibular augmentation is needed in group III and II cases and
mandibular augmentation for implant utili6ation is needed when severe
resorption will not allow acceptable fixture height in position because of
lack of ade7uate bone. .ugmentation also is indicated when population of
the implant sites may lead to mandibular fracture or when pathologic
fracture is a concern.
<A
The permanence of the bony reconstruction of the mandible has
historically been a problem. pichler and Traunec in 2A;@ whole that
clementschitch may have been the pioneer in the construction of the
alveolus of the mandible using blocks of autologous ilium. 5any other
followed using autologous ilium but it was found that the grafted area
tended to resorts after a four months and had often completely disappeared.
.fter a few years *bwegeser and )o=workers introduced the
application of autologous eris in this problem. this graft tended to last
somewhat longer. Thus the grater proportion of cortex to spongiosa of rib
appeared to suggest that the more cortical bone present in the graft the
longer the grafted area tended to remain the grater amount of cortical bone
results with a prolonged resorption and replacement phase while the graft
changes to viable lamellar bone. It appeared possible that if a non
resorbable substance could be substituted for the function of the cortical
bone the highly osteogenic autoglosus cancellous bone might form a
composite that could last indefinitely Icent and coworkers appeared to
validate this hypothesis by adding dense via to autogenous cancellous bone.
This mixture revealed less than 2<B resorption at ; years after grafting.
Thus the problem of the retention of the grafted bone for strength of
the mandible has substantially been solved by the addition of dense #. to
the bone graft material. #owever when this type of grafting system is used
for implant sites when the implants are to be placed after graft maturation
the dense #. presents a problem on that it is difficult to through it.
Therefore dense #. and bone are best used when a graft is to be placed
around a implant.
%C
.nother splints to substitute the porous form #. for the dense form
as porous can be drilled. It was generally considered that the porous form of
#. would be long lasting it is sometimes reform non resorbed. #ence it
appears appropriate to use porous #. mixed with the bone graft in areas
where implants are to be placed and dense #. mixed with the bone graft
when strengthening only is re7uire.
CONCLUSION
"esorption of alveolar bone seems inevitable when teeth are lost yet
variability exists between persons. 3oth between and within the !aws and
over time. It would seem that bone that has undergo higher rates of
resorption initially will continue to resorbs excessively compared with bone
that has undergone lower rates of resorption.
5etabolic differences are undoubtedly most significant in the
response of a given individual to a given stress and account for the
variations among individuals within the same individual at different times.
The state of knowledge is so inade7uate 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. De must rely on clinical !udgement. Dhich is
notoriously poor we revaluate the general nutrition metabolism and hormal
activity of the patient sometimes age or sex provides clues. . dental history
of or clinical evidence of inordinate previous bone loss may suggest a poor
bone factors but such bone loss must be evaluated in light of the anatomic
functional and prosthetic factors. The findings although not statistically
significant suggest that clinical !udgement of prosthodontics depends not
only on a profound.
%2
(nderstanding of the myriad of significant technical factors but also on the
understanding of the complex interrelationship of these technical factors
with anatomic metabolic and functional factors. T/-# -# 6/at %ak(#
&!"#t/"3"1t-+# +/a))(10-10: T/-# -# 6/at %ak(# &!"#t/"3"1t-+# ,81:
%$
REFERENCES
2) /ammie 0... 4 "eduction of the edentulous ridges. J.1.'. 2C 4 %C<=
%22 2A%C.
$) -obolik ).,. 4 .lveolar bone resorption. J.1.'. 2C 4 %2$=%2A 2A%C.
9) .twood '... 4 -ome clinical factors related to the rate of resorption
of residual ridge. J.1.'. 2$ 4 ;22=;<C 2A%$.
;) *rtman #.". 4 ,actors of bone resorption of the residual ridge.
J.1.'. 2$ 4 ;$A=;;C 2A%$.
<) .twood '... 4 "eduction of residual ridges 4 . ma!or oral disease
entity. J.1.'. $% 4 $%%=$>A 2A>2.
%) ,enton '.#. 4 3one resorption and prosthodontics. J.1.'. $A 4 ;>2=
;29 2A>9.
>) Ieisey /./. 4 .lveolar bone resorption of prosthodontics. J.1.'. $< 4
2<$=2%2 2A>9.
@) +eufeid J.*. 4 )hanges in the trabecular pattern of the mandible
following the loss of teeth. J.1.'. @ 4 %@<=%A> 2A<@.
A) Dyatt )./. 4 The effect of prosthodontic treatment on alveolar bone
loss 4 . review of the literature. J.1.'. @C 4 9%$=9%; 2AA@.
2C) .twood '... 4 3one loss of edentulous alveolar ridge.
22) Iapur I.I. 4 The effects of complete denture on alveolar mucosa.
J.1.'. 29 4 2C9C 2A%9.
%9
2$) Turck '. 4 . histologic comparison of the edentulous denture and
non denture bearing tissue. J.1.'. 2< 4 ;2A 2A%<.
29) 1ietro Iovski 4 The bony residual ridge in man. J.1.'. 9; 4 ;<%
2A><.
2;) &nlow '.#. 4 The remodeling of the edentulous mandible. J.1.'.
9% 4 %@< 2A>%.
2<) 1aul 5ercier 4 "idge reconstruction with hydroxylapatite. J. *ral
-urg. <C< 2A%@.
2%) 3aylink J.'. 4 -ystemic factors on alveolar bone loss. J.1.'. 92 4
;@% 2A>;.
2>) /eka Jahangeri 4 )urrent perspectives in residual ridge remodeling
and its clinical implications 4 . review. J.1.'. @C 4 $$; 2AA@.
2@) )urtis ..T. 4 .utogenous bone graft procedure for atrophic
edentulous mandibles. J.1.'. 9@ 4 9%% 2A>>.
2A) Dendt. ).'. 4 The degenerative denture ridge=care and treatment.
J.1.'. 9$ 4 ;>> 2A>;.
$C) Dinkie ". 4 &ssentials of complete denture prosthodontics.
%;
CONTENTS
2) Introduction
$) +ormal .lveolar 3one 1hysiology
9) Tooth &xtraction Dound #ealing .nd ,ormation *f The
"esidual 3one
;) 3one "emodelling 1rocess
<) #istological *bservation *f "esidual 3one "esorption
%) ,actors .ffecting "esidual "idge "esorption
>) 'iagnostic .ids To 'efect "rr
@) 1attern *f 3one "esorption .nd .natomical )onsideration
A) )linical -ignificance
2C) )onclusion
22) "eferences
%<
CONTENTS
 Introduction
 ,unctions of 5axillofacial -tructures
 &stablishment of Gertical 5axillomandibular "elations for
)omplete 'entures
 5ethods of 'etermining Gertical "elation
 1hysiological 5ethods
 1honetics .s a 0uide
 Tests of Gertical Jaw relations with occlusion rims
 The speaking method
 The closest speaking space and the free=way space
 Techni7ue with existing dentures
 Techni7ue without records or dentures
 1honetics in orientation of anterior teeth
 /abiodental -ounds
 'ental and alveolar sounds
 1alatal and velar sounds
 1atient adaptation in phonetics
 1alatal contour of the 'enture
 1alatography for proper palatal contour
 'iscussion
 )onclusion
%%