RESIDUAL RIDGE RESORPTION

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Introduction

Residual ridge resorption is a normal physiologic process and is

not a disease. But this is labeled as a disease because of the wide

variation in the rate of residual ridge resorption.

Definition

According to GPT-7, residual ridge resorption is a term used for

the diminishing quantity and quality of the residual ridge after the

teeth are removed.

Classification

1. Atwood classified residual ridge resorption into:

 Order 1: pre-extraction

 Order 2: post-extraction

 Order 3: high, well-rounded

 Order 4: knife-edged

 Order 5: low, well rounded

 Order 6: depressed

2. Neil classified residual ridge resorption in relation with floor of

the mouth and mylohyoid ridge:

 Class 1: 0.5 inch space exists between mylohyoid ridge

and the floor of the mouth.

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  Class 2: Less than 0.5 inch space exists between

mylohyoid ridge and the floor of the mouth.

 Class 3: the mylohyoid muscle is at the same level as the

mylohyoid ridge.

3. Branemark classified residual ridge resorption depending on

bone quality and quantity:

Bone quantity

 Class A- Most of the alveolar bone is present.

 Class B- Moderate residual ridge resorption occurs.

 Class C- Advanced residual ridge resorption occurs.

 Class D- Moderate resorption of the basal bone occurs.

 Class E- Extreme resorption of the basal bone occurs.

Bone quality

 Class 1- Almost the entire jaw is composed of homogenous

compact bone.

 Class 2- a thick layer of compact bone surrounds a core of dense

trabecular bone.

 Class 3- a thin layer of compact bone surrounds a core of dense

trabecular bone.

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  Class 4- a thin layer of compact bone surrounds a core of low-

density trabecular bone.

Pathology

The basic structural change in RRR is a reduction in the size of

the bony ridge under the mucoperiosteum. Residual ridge resorption is

a localized loss of bone structure. To categorize the most common

residual ridge configurations, Atwood has described the six orders of

residual ridge resorption. But there may be porosities and

imperfections in the crestal areas of residual ridges of both maxilla and

mandible, no matter at what stage of configuration they are. RRR does

not stop with residual ridge. This ridge resorption can continue till

only a thin cortical plate is left on the inferior border of the mandible

and in maxilla it continues till there is no alveolar process left.

Lateral cephalometric radiographs provide accurate method for

determining RRR.

The panoramic radiograph technique described by Wical and

Swoope is a simple, useful method for determining RRR.

Procedure

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 Original alveolar crest height is determined by measuring the

distance from the inferior border of mandible to the lower edge of the

mental foramen after superimposing both the lateral cephalometric

radiographs.

Clinically, the soft tissues overlying the residual ridges may

range from normal to inflamed, edematous, ulcerated, indented or

abused tissue.

Microscopic studies show the presence of osteoclasts on the

external surface of the crest of residual ridges.

Pathophysiology

Bone undergoes constant remodeling throughout life. Normally

bone formation is equal to bone resorption. But in osteoporosis bone

resorption is greater than bone formation. RRR is a localized

pathologic loss of bone that is not built back by removing the causative

factors.

Bone remodeling takes place even in the presence of this

pathologic osteoclastic activity. A cortical layer of bone is present

over the crest of the ridge even during RRR, which clearly shows the

formation of new bone.

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 If endosteal bone growth fails to keep pace with external

osteoclastic activity, then medullary bone would be exposed resulting

in defects on the crest of the ridge.

Pathogenesis

RRR is chronic, progressive, irreversible and cumulative. It

proceeds slowly over a long period of time, flowing from one order to

the next order.

Order 1------order 2------order 3-------order 4-------order 5------order 6

Order 1 to order 2: after extraction

Order 2 to order 3: external osteoclastic resorption

Order 3 to order 4: resorption on labial and lingual aspects

Order 4 to order 5: more resorption

Order 5 to order 6: final stage

Consequences of RRR

1. Loss of sulcus width and depth with displacement of the muscle

attachment closer to the crest of the residual ridge.

2. Loss of vertical dimension of occlusion.

3. Reduction of the lower facial height.

4. Anterior rotation of the mandible and increase in relative

prognathia.

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 5. Changes in inter alveolar ridge relationship.

6. Morphological changes of the alveolar bone such as sharp spiny

uneven residual ridges.

Etiology of RRR

RRR is a multi factorial and biomechanical disease. 3 major

factors lead to RRR. They are:

1. Anatomic factors

2. Metabolic factors

3. Mechanical factors

Anatomic factors

RRR  anatomic factors

Presence of more bone will lead to more RRR. Large well

rounded ridges and broad palates are favorable anatomic factors for

RRR.

Metabolic factors

RRR  bone resorption factors / bone formation factors.

Local bone resorbing factors like endotoxins, osteoclast

activating factor (OAF), prostaglandins, human gingival bone-

resorption stimulating factor, heparin and trauma lead to RRR.

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 Bone forming factors are circulating estrogen, thyroxine, growth

hormone, androgens, calcium, phosphorus, vitamin D, protein and

fluoride.

Mechanical factors

Force is the main factor in RRR.

RRR  force

While considering force, one must also consider:

1. Amount of force

2. Frequency of force

3. Duration of force

4. Direction of force

5. Force per unit area

Also, force applied to the bone is affected inversely by the

damping effect of the underlying tissue. Damping effect is the energy

absorption in the mucoperiosteum.

RRR  1 / damping effect

So residual ridge resorption is related to the etiologic factors in

the following manner:

Anatomic factors

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RRR  Bone resorption factors / bone formation factors

Force factors / damping effect factors

1 / time

This time is the time taken since extraction to the bone loss in

residual ridge resorption.

Treatment

Treatment for residual ridge resorption is of two types:

1. Non-surgical

2. Surgical

Non-surgical treatment

1. Prevention of RRR.

2. Prevention of tooth loss.

3. Prevention of the deficiency of hormones, vitamins and minerals.

Surgical treatment

1. Ridge corrective procedures

2. Ridge extension procedures.

3. Provision of accessory undercuts.

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Ridge corrective procedures

1. Soft tissue correction

2. Hard tissue correction

Soft tissue correction

1. Labial frenectomy

2. Lingual frenectomy

3. Mobile tissue on the alveolar ridge

4. Enlarged tuberosity

5. Enlarged retromolar pad

Hard tissue correction

1. Shaping unsuitable bony ridge

2. Alveolectomy

3. Elimination of unfavorable undercut

4. Excision of tori

Ridge extension procedures

1. Vestibuloplasty

2. Ridge augmentation procedure

Provision of accessory under cuts

1. Creating favorable under cuts

2. Dental implants

3. Onlay denture

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Prosthetic considerations

Design of the denture should aim at reducing the amount of force

on the ridge there by reducing residual ridge resorption. They include:

1. Broad area coverage to reduce the force per unit area

2. Decreased number of dental units

3. Decreased buccolingual width of teeth

4. Improved tooth form to decrease the amount of force required to

penetrate a bolus of food

5. Avoidance of inclined planes to minimize dislodgement of

dentures and shear forces

6. Centralization of occlusal contacts to increase stability of

dentures and to maximize compressive forces

7. Provision of adequate tongue room to improve stability of

denture in speech and mastication

8. Adequate interocclusal distance during rest jaw position to

decrease the frequency and duration of tooth contacts

Impression procedures for RRR

1. Preliminary impression, which is generally over extended

2. Cast is poured

3. Resin tray and occlusal rim are made and tried in the mouth

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 4. Borders are adjusted so that the lingual flange and sublingual

crescent area are in harmony with the resting and active phases

of the floor of the mouth in the mandibular arch

5. The buccal and lingual extensions of the tray are adjusted just

short of the reflections of the cheek and lip min the mandibular

arch

6. Peripheral borders are thicker and peripheral seal should be

maintained in the maxillary arch.

7. Now a stable and non-retentive tray is available

8. Now a closed mouth or open mouth technique is used to make a

master impression

9. Tissue conditioners are used to make the impression of the

resorbed ridge.

Conclusion

Resorption of the residual ridges is common. The rate of

resorption varies among different individuals and also in the same

individual at different times. Dentist should understand the factors

causing the residual ridge resorption and treat the patient accordingly

using the different treatment options.

References

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Arthur O Rahn, Charles M Heartwell: Textbook of complete

Dentures, Ed 5, London, 1993; P No: 131-158.

George A Zarb, Charles L Bolender, Judson C Hickey, Gunnar E

Carlsson: Boucher’s prosthodontic treatment for edentulous patients,

Ed 10, B.I Publications Pvt. Ltd. P No: 51-70.

John J Sharry: Complete Denture Prosthodontics, McGrawhill Book

Company, Inc. 1962; P No 147-152.

Robert L Engelmeier, Rodney D Phoenix: Patient evaluation and

Treatment Planning for complete – Denture Therapy, Dental clinics of

North America, 1996; Vol 40 : No:1; P No 1-11.

Sheldon Winkler: Essentials of complete Denture Prosthodontics, ed

2, Ishiyaku Euro America Inc. P No 39-55.

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