ALVEOLAR BONE – ANATOMY,PHYSIOLOGY

AND SUBSEQUENT FATE AFTER EXODONTIA.

BY DR. ABHYUTTHAN SINHA

1ST YEAR MDS

GUIDED BY –

DR. ASHISTARU SAHA

DR. ANUPAM PURWAR

DR. PRANAY MAHASETH

WHAT IS ALVEOLAR BONE?

Alveolar bone is defined as that part of the maxilla and the mandible that forms and supports the
sockets of the teeth.

One of the most remodelled bones in the body..

FUNCTIONS -

Houses roots of the teeth.

Anchors the roots of the teeth to the alveoli by the insertion of periodontal ligament into
the alveolar bone proper.

Helps to move teeth for better occlusion.

Helps to distribute the occlusal forces that arise from tooth to tooth contact.

Houses blood vessels to the PDL.

Houses and protects developing permanent teeth while supporting primary teeth.

Organises eruption of primary and permanent teeth

DEVELOPMENT-

According to orban, “an alveolar process in the strict sense of the world develops only during the
eruption of the teeth.”

Near the end of the second month of fetal life.

The maxilla and the mandible forms a groove that is open to the surface of the oral cavity and
contains tooth germs, alveolar bone, vessels and nerves.

Gradually bony septae separate the tooth germs and a horizontal plate separates the primitive
mandibular canal from the alveolar bone.

STRUCTURE -

Alveolar bone

Alveolar bone proper supporting alveolar bone

Lamellated bone bundle bone cortical bone spongy bone

ALVEOLAR BONE PROPER -

It is a thin lamella of bone that surrounds the root of the tooth and gives attachment to the
principal fibres of the PDL.

Also known as the “cribiform plate” as it is perforated by vessels and nerves.

LAMELLATE BONE-

Some lamellae of the lamellated bone are arranged roughly parallel to the surface of the adjacent
marrow space, whereas others form haversian systems.

BUNDLE BONE -

Bundle bone is that bone in which principal fibres of the PDL are anchored.
Bundles of principal fibres run into the bone as Sharpey’s fibres.

As compared to lamellate bone, microscopically it has less fibrils.

Increased radio-opacity causes it to be named as the bundle bone.

Radiologically it is known as the lamina dura.

SUPPORTING ALVEOLAR BONE –

CORTICAL PLATES

Consists of compact bone and forms the inside and outside of the alveolar process.

Thickest in premolar molar region.

Thinner in the maxilla and thicker in the mandible.

SPONGY BONE

Fills the area between the cortical plates and the alveolar bone proper.

It is of 2 types-

Type 1- regularly arranged interdental and interradicular bone n step ladder fashion

Type 2-irregularly arranged bone mostly in maxilla.

INTERNAL RECONSTRUCTION OF THE ALVEOLAR BONE -

Alveolar bone remodells according to need.

Osteoblasts and osteoclasts are the main executives of this phase and bring about a balance of
resorption and apposition that progresses remodelling.

PHYSIOLOGIC BALANCE -
Teeth erupt mesio-occlusally

Bone apposition takes place distally while bone resorption takes place mesially.

Apposition brought about by the osteoblasts while resorption takes place in bay like Howship’s
lacunae showing the presence of multinucleated osteoclasts.

Compact bone and spongy bone tend to alternate between each other.

Periods of resorption follow periods of rest and repair. This is the time of formation of bundle
bone, which remains loosely attached to the lamellated bone.

WOLFF’S LAW -

Out of all the factors that determine bone remodelling, this one takes special mention.

Wolff’s law states that bones tend to remodel under stress and strain. More deposition taking
place in areas of stress.

Bent bones show increased appostion as they are most likely to buckle.

Experiments suggest that mechanical forces are converted to electrical signals that cause
remodelling of the bones.

FATE OF ALVEOLAR BONE AFTER EXODONTIA -

Following extraction the alveoli fill up with blood, which sequentially clots, is organised and
replaced with new bone.

Its existence as a pathology has been a topic of controversy for many years amongst eminent
scientists.

Though recent advancements have shown that it is a physiologic process.

RESIDUAL RIDGE RESORPTION [RRR] -

The remaining alveolar ridge undergoes resroption throughout life but at different rates for all
idividuals. So it is important for prosthodontists to have a maintenance phase following their
treatments which is to be carried out throughout their lives.
DIAGNOSIS -

Diagnosis of residual ridge resorption has been seen to be most accurate in periodic lateral
cephalometric radiographs initially.

In later years, wical and swoope used opg as a simpler way to find out rrr.

In the new era with the advent of ct scan and cbct techniques, rrr has become easier to be
observed.

FACTORS AFFECTING RRR -

Anatomic factors

Localised mechanical stress from removable prosthesis

Osteoporosis and post menopausal changes

Role of inflammatory mediators.

MICROSCOPY -

Presence of osteocalsts in scalloped borders of howship’s lacunae are found on the external
surface of the crest of the ridges.

Some amount of bone deposition and repair has also been found due to presence of reversal line.

The bone covering the crest is either cortical or without any covering and having only medullary
bone beneath.

RATE -

Initial studies have shown that maximum resorption of the alveolar bone occurs in the first 2
years after exodontia.

Recent studies have shown that this resorption is fastest in the first 3 months and then continues
at a uniform pace throughout life.

DIFFERENCE IN RRR OF BOTH JAWS -

Woelfel et al (1974, 1976) have cited the projected maxillary denture area to be 4.2 sq.in and 2.3
sq.in for the mandible; which is in the ratio of 1.8:1. If a patient bites with a pressure of 50 lbs,
this is calculated to be 12 lbs/sq in under the maxillary denture and 21 lbs/sq under the
mandibular denture.

The mucoperiosteum due to its ‘spongy’ nature has a ‘dampening effect’ on the forces that are
transmitted to the alveolar ridge.

IMPORTANCE OF REDUCING RRR -

Any technique that ensures the preservation, augmentation or reconstruction of the alveolar ridge
height, thickness and quality, immediately after dental extraction, treatments must be carried out
for the maintenance of its vertical and horizontal dimensions. (Aimetti et al, 2009; Lekovic et al,
1998)

These include guided bone regeneration, with or without grafting material, grafting with bone
substitutes, osteogenic materials, such as autogenous bone marrow and plasma rich in growth
factors (PRGF); and other biomaterials.

The grafting materials used as bone fillers after tooth extraction provide mechanical support and
prevent the collapse of both the buccal and lingual bone walls, thus delaying residual ridge
resorption .The ideal bone substitute should be both osteoinductive and osteoconductive in
nature, stimulating and serving as a scaffold for bone growth.

PROSTHODONTIC PRINCIPLES TO REDUCE RRR -

Certain general principles must be kept in mind during fabrication of complete dentures which
will help to reduce the stress transmission and help preserve the alveolar ridge.

This may be achieved by having broad area of coverage under the denture base (to reduce the
force per unit area).

A decrease in the number of denture teeth; decrease in the buccolingual width of teeth; improved
occlusal tooth design form (to decrease the amount of force required to penetrate a bolus of food)
are some of the other techniques that may also be used.

During tooth setup the aim should be to reduce the number of inclined planes (to minimize
dislodgement of dentures and shear forces) and achieve a centralization of occlusal contacts (to
increase stability of dentures and to maximize compressive load).

Accurate recording of maxillomandibular relationship will ensure optimum vertical rest

dimension which will decrease the frequency and duration of tooth contacts, thereby giving
adequate rest to the underlying ridges. (Kapur & Soman, 1964; Van Waas, 1990)

TREATMENT MODALITIES TO MANAGE RRR –

SURGICAL APPROACH –

Vestibuloplasty is the first line of surgical treatment of resorbed ridges when surgery is to be
considered.

Other techniques involved maybe distraction osteosynthesis of the alveolar bone.

PROSHTETIC APPROACH –

Conventonal complete dentures reduce the rate of resorption

Removable partial dentures with proper reciprocal arm designs

Fixed partial prosthesis without extremely tight contacts

Implants help to reduce residual ridge resorption

IMPLANT SUPPORTED DENTURES –

CONCLUSION -
It is imperative for all prosthodontists to know the cause , rate and fate of alveolar bone
resorption after tooth loss and also its basic anatomy and physiology so as to harness its potential
and guide its resorption for better treatment delivery and logeivity of delivered prostheses. All
for a better life for the patient and glory of the profession.

REFERRENCES –
ZARB-BOLENDER , 13TH EDITION, PROSTHODONTIC TREATMENT FOR
EDENTULOUS PATIENTS.

SHELDON WINKLER , 3RD EDITION, ESSENTIALS OF COMPLETE DENTURE

PROSTHODONTICS.

RESIDUAL RIDGE RESORPTION – REVISISTED, DR. DEREK D’SOUZA

ORBAN’S ORAL HISTOLOGY AND EMBRYOLOGY , 13TH EDITION.

CE MISCH, 3RD EDITION, CONTEMPORARY IMPLANT DENTISTRY.

THANK YOU