RESEARCH AND EDUCATION

JOHN J. SHARRY, Section editor

The remodeling of the edentulous mandible

Donald H. Enlow, Ph.D.,* Henry J. Bianco, D.D.S.,* and

Stephen Eklund, D.D.S.**
West Virginia University, School of Dentistry, Morgantown, W. Vu.

T his study describes the distribution of surface fields of resorption and deposition
in all parts of the edentulous mandible. These remodeling fields relate to the marked
alterations in regional shape and dimensions of key parts of the whole mandible
associated with complete or nearly complete loss of dentition. Some of the changes
involved are consistently observed from mandible to mandible, but others are variable
in individual specimens.
Previous reports have described the distribution of resorptive and depository
fields involved in the growth and remodeling of the mandible from childhood to
adult years.l The histologic criteria used to identify the various kinds of resorptive
and depository surfaces were also described. The distribution pattern of remodeling
fields in the young, growing mandible is illustrated in Fig. 1. Remodeling of the
child’s mandible is a basic part of the growth process itself and functions not only
to enlarge the various parts of the bone but, importantly, to subsequently relocate
these parts as the whole bone continues to increase in size. The ramus, for example,
becomes relocated in a progressively posterior direction as the corpus simultaneously
lengthens into regions previously occupied by the ramus. These remodeling changes
require selective fields of surface resorption and deposition to bring about the re-
quired complex three-dimensional growth movements (Fig. 1). All other parts of
the growing mandible are similarly involved in localized processes of relocation and
remodeling.’
The childhood growth fields remain recognizable in adult, nongrowing mandibles
with full dentitions. That is, the surface histologic characteristics related to past
resorptive and depository activities can still be distinguished in the adult form even

This study was supported, in part, by United States Public Health Service grant DE 03761-
02.
*Departments of Anatomy and Prosthodontics, West Virginia University, School of Den-
tistry.
**Chief, Service Unit Dental Program, Indian Health Service, Many Farms, Ark.

685
606 Enlow, Bianco, and Eklund J. Prosthet. Dent.
December, 1976

Fig. 1. The patterns of bone deposition (light stipple) and resorption (dark stipple) that carry
out the growth and remodeling changes in the young mandible are shown. Compare these
patterns with the distribution of remodeling fields in the edentulous mandible (Fig. 2).

though the growth changes themselves have ceased. While through the years the
internal structure of the cortical bone becomes progressively replaced by osteons,
the surface features as well as the underlying stratification produced during child-
hood remain largely identifiable. In relation to extensive losses of teeth, however,
remodeling of the shape and regional size of the mandible becomes involved, and
it is the pattern of these changes that will be described in this report. The distribution
of remodeling fields in the edentulous mandible differs markedly from that of the
young, growing, fully dentulous mandible.
With loss of teeth, the functional and structural relationships of the whole adult
mandible change, and specific remodeling responses are the functional result. This
involves altered occlusal relationships, rotations of the entire mandible, realignment
of the mandibular corpus, redesign of the morphology of the corpus, altered muscle-
to-bone alignments, changes in locations of muscle attachments, and decreased areas
for muscle insertion. This report describes remodeling processes that produce the
varied changes in regional form and size of the mandible in response to some or
all of these altered functional relationships,

MATERIALS AND METHODS

The methods used herein are the same as those used to determine patterns of
growth and remodeling in the mandible and all other bony elements of the skull in
the growing child. Fifteen mandibles at various stages of tooth loss were selected
for study. Of these, 10 did not involve any artificial teeth. Nine specimens were
completely edentulous, and six retained two or three anterior or posterior teeth. NO
significant differences in the range of variations were found among these different
groups of specimens.
Transverse, ground serial sections were prepared through the entire left half of
each mandible from the condyle to the chin. The periosteal surface of each section
was then analyzed as to the resorptive or depository nature of all areas around its
perimeter. A three-dimensional mapping of the serial sections was done to show the
 Remodeling the edentulous mandible 607

Fig. 2. The remodeling changes that take place in the mandible in relation to the loss of teeth
result in major regional changes in shape and dimensions. This is a composite diagram illus-
trating the most commonly observed regional remodeling patterns that bring about these struc-
tural changes in the edentulous mandible. Resorption is represented by dark stippling and
deposition by light stippling.

over-all distribution of resorptive and depository fields for each mandible. The dis-
tribution patterns of these remodeling fields for all mandibles were compared, and
common patterns of remodeling changes as well as major variations were determined.

OBSERVATIONS
Fig. 2 represents a composite diagram of the most frequently observed combina-
tions of resorptive and depository fields for the sample. Fig. 3 is a profile overlay
showing some two-dimensional effects. As a consequence of these remodeling pro-
cesses, various morphologic changes (to be outlined) are produced. The regions in
which the changes occur are indicated in Fig. 4 by the numbers corresponding to
each of the following descriptions.
(1) The over-all horizontal length of the bony mandibular arch does not decrease
and may actually increase since (a) the mental protuberance is a depository type
of remodeling field and (b) resorption occurs along the vertical length of the anterior
border of the ramus and the temporal crest, thereby adding to the horizontal length
of the corpus (see also IO). When resorption takes place on either the periosteal
or the endosteal side of a bony cortex, deposition ordinarily occurs on the opposite
surface of that same cortex. The whole cortical plate thus moues in either an end-
osteal or a periosteal direction without significant change in cortical thickness. An
exception involves osteoporosis, in which noticeable thinning of the cortex can occur
due to a greater extent of resorption on one side or a lesser extent of deposition on
the other.
While the chin region in the edentulous mandible is a “depository” surface, it
is not presently known whether active deposition actually takes place following loss of
teeth. This depository surface of bone may be the same surface, but in an inactive
state, that was laid down during the late childhood period. However, the point to
680 Enlow, Bianco, and Eklund J. Prosthet. Dent.
December, 1976

Fig. 3. The structural results of the remodeling changes caused by the resorptive and depository
fields illustrated in Fig. 2 are represented in this two-dimensional (before-and-after) overlay.
The remodeling changes are depicted by the broken line.

be made is that the mental region does not become actively resorptive in the edentu-
lous mandible, a process that results in a regional regression.
(2) The over-all breadth of the bony arch can increase due to the presence of
a depository field along its lateral (buccal) sides. The arch becomes somewhat more
squared and less V-shaped. The breadth of the corpus itself from the buccal to the
lingual cortex is increased due to depository fields on both sides. However, specific
remodeling variations in about half of the specimens studied resulted in a decrease,
not increase, in arch width (to be described later) .
(3) Alveolar involution in inferior and posterior directions occurs in the incisor
region of the edentulous mandible, and the alveolar bone is progressively reduced
to a residual ridge. The posterior direction of this alveolar remodeling change does
not significantly affect the basal bone, which actually may have an anterior direction
of increased corpus growth at the chin (or at least an absence of resorption). Com-
bined with (a) a regression of maxillary alveolar bone back to the more posteriorly
located area of maxillary basal bone, (b) a forward rotation of the whole edentulous
mandible at the condylar pivot, and (c) a more downward angulation of the corpus
at its junction with the ramus (which has the effect of lengthening the over-all
dimension of the mandible), a marked protrusion of the mandible results.
While a destructive removal of the alveolar processes occurs, a constructive addi-
tion of bone takes place simultaneously within the depths of the edentulous sockets.
Note the difference in the locations of the reversal lines (between the areas of
resorptive alveolar and depository basal bone) on the lingual as compared with the
labial sides in the anterior part of the arch. The line is much lower on the labial
side. Major variations from this pattern were infrequent in the mandibles studied.
The labial and lingual reversal lines represent the most inferior extent to which
alveolar reduction is likely to progress unless overridden by heavy mechanical or
unusua.1 physiologic factors. Resorptive reduction is less marked and characteristically
more stable on the lingual in contrast to the labial side in the incisor and canine
 Remodeling the edentulous mandible 689

Fig. 4. The numbers in these two views of the edentulous mandible correspond to the regional
descriptions in the text.

region. This region is often elevated well above the premolar and molar regions in
the edentulous mandible and is associated with the higher placement of the reversal
line in the anterior-lingual part of the jaw. These observations also correlate with
the posterior directional tendency of alveolar reduction in the incisor region, since,
due to its resorptive nature, the labial cortical plate moves in a more posterior direc-
tion than the lingual plate. The labial cortex, further, is noticeably thin in contrast
to the lingual side, which retains substantial thickness.
(4) An inferior course of alveolar resorption occurs on the dorsum of the corpus
from the canine through the molar regions. The reversal line on the lingual side
between the resorptive alveolar field and the depository field of the basal bone tends
to be much lower than in the incisor region and usually occurs along the oblique
. .
mylohyold Ime. The residual ridge in the premolar and molar regions thus shows
a pronounced dishing as it grades back from the more elevated incisor region, even
in fully edentulous specimens. Cause-and-effect factors involved in the placement of
these various reversal lines are not now known.
(5) Along the inferior border of the corpus, bone deposition takes place through-
out its length except in the antegonial region.
(6) The inferior border of the corpus in the antegonial region is resorptive. This
is associated with a more downward alignment of the entire corpus relative to the
ramus, a change that contributes to the occlusal closure of the forward-rotated eden-
tulous mandible. The forward and upward rotation of the whole mandible in con-
junction with loss of dentition is offset, at least in part, by this remodeling adaptation
of the mandibular body at its junction with the ramus. This alignment change pro-
duces a more pronounced antegonial notch, the extent of which is further increased
by (a) deposition along the ventral border of the entire length of the corpus together
with (b) resorption in the notch itself. Note the marked convex curvature of the
ventral profile of the body as it grades into the prominent concave antegonial notch
and relatively high genial region (the ventral border of the latter also tends to be
690 Enlow, Bianco, and Eklund J, Prosthet. Dent.
December, 1976

resorptive) . A typical Class III type of mandible with full dentition also often shows
this antegonial notching effect. Likewise, this occurs in conjunction with a downward
alignment of the corpus relative to the ramus in response to a forward and upward
rotation of the whole mandible at the condylar pivot. In many patients with a Class
III jaw relationship, this is associated with a relatively short, vertical midface dimen-
sion.”
However, the genial angle itself is not necessarily changed by these various re-
modeling alterations, since differential extents of resorptive activity along the pos-
terior border of the ramus can result in more or less constant gonial angulation.”
(7) Bone deposition along the entire lateral side of the basal bone of the corpus
produces a more pronounced lateral protrusion of the trihedral eminence. This adds
to the squaring effect of the bony arch as a whole.
(8) On the medial (lingual) side of the corpus, generalized deposition of bone
occurs inferior to the mylohyoid line. This extends into the lingual fossa, and the
fossa tends to become filled and leveled.
(9) A reversal exists along the crest of the mylohyoid line. Superiorly, the alve-
olar surface is resorptive. In combination with the depository field of remodeling
in the lingual fossa, just below the resorbing alveolar region, the breadth of the basal
part of the body becomes widened and the overlying alveolar region becomes
markedly pattened.
(10) Both the posterior (10) and the anterior borders (lb) of the ramus (and
the contiguous temporal crest) are resorptive in nature. This narrows the postero-
anterior breadth of the ramus. Since the extent of backward remodeling of the
anterior border approximates the amount of forward remodeling on the posterior
border, the relative positioning of the mandibular foramen remains fairly constant
(about midway) between the two margins. The edge of the gonial region moves
anteriorly and superiorly due to a resorptive field on its posterior and inferior sur-
faces.
The occurrence of a resorptive surface on the anterior border of the ramus serves
to accommodate the mass of the temporal muscle between the ramus and maxillary
tuberosity as the whole ramus rotates toward the tuberosity due to dentition loss and
edentulous occlusal closure. The region of the anterior ramus border that abuts the
maxillary tuberosity during edentulous occlusion shows a pronounced notching. This
can give the coronoid process a flared and somtimes hooklike configuration.
(l.l) Following tooth loss, resorption in the inferior region of the anterior border
of the ramus also functions to align the surface contour of this region with the re-
sorptive surface on the posterior part of the dorsum of the corpus.
(12) The subcondylar region on the anterior side of the neck is resorptive. This
produces a localized dishing effect. The resultant cortical depression accommodates
the abutment of the articular tubercle of the glenoid fossa during edentulous occlusal
closure.
(13) The lingual side of the coronoid process and the ramus just inferior to
the si,mnoid notch are both depository regions. The contralateral buccal side is re-
sorptive. Since the lingual surfaces of these parts face superiorly, this combination
results in an elevation of the sigmoid notch, a vertical lengthening of the ramus in
 Remodeling the edentulous mandible 691

a superior direction, and an elongation of the coronoid process. The latter usually
rises well above the level of the condyle in many edentulous mandibles (a much less
frequently encountered variation involves an actual shortening of the coronoid
process).
(14) The presence of bone resorption on the lingual side of the gonial region
along with deposition on the buccal side produces a tendency toward a flaring and
buccal protrusion of this region. However, a similar tendency can also be found in
many adult, tooth-bearing mandibles.

VARIATIONS
Of the 15 mandibles analyzed in this study, four showed variable regions of
deposition in the posterior part of the ramus on the lingual side. This remodeling
variation results in a lingual movement of this region that brings it more into line
with the axis of the corpus (in the dentulous mandible, this region of the ramus lies
well to the lateral of the arch).
In six specimens, a large field of resorption occurred on the lateral side of the
corpus anterior to the trihedral eminence (which remains depository) . The remodel-
ing effect is to narrow rather than widen the arch of basal bone and to make the
arch more V-shaped.
Both the buccal and lingual sides of the basal bone cortex of the corpus anterior
to the trihedral eminence (i.e., the former premolar and canine areas) were re-
sportive in four specimens. This reduces the transverse thickness of each corpus
and narrows the over-all arch width, The more stable inferior border of the corpus,
however, remains depository in nature, so that the vertical dimension becomes
reduced only by the resorption of the alveolar area.
In three specimens, the buccal side of the basal bone cortex in the former pre-
molar and canine regions is resorptive, but the lingual side is depository. This com-
bination reduces arch width in this part of the mandible, although the transverse
breadth of each corpus is not decreased to the extent seen in the previous remodeling
variation.
A resorptive surface in the entire region of the lingual fossa was found in seven
specimens. Thereby, a reduction in transverse corpus thickness from the lingual
cortex results in this region. The depth of the fossa is increased in these particular
mandibles in conjunction with a marked resorptive flattening of the overlying al-
veolar process previously housing the molars.
In six of the specimens, the inferior part of the ramus on the buccal side was
entirely resorptive. Because the contralateral lingual side also was resorptive in these
same mandibles, the effect was to reduce the cortex-to-cortex thickness of each ramus
by reducing the volume of the medullary area between the cortical plates (the
endosteal sides of each cortex are depository).
Seven specimens showed a resorptive lingual surface in the region anterior to
the mandibular foramen. This results in a thinning of the region and a depression
of this area, reducing and flattening the edge of the temporal crest. It also results
in a decreased area for temporal muscle attachment.
Resorption on the lingual side of the basal bone cortex in the former premolar
692 Enlow, Bianco, and Eklund J. Prosthet. Dent.
December, 1976

and canine regions together with deposition on the contralateral buccal side was found
in three mandibles. This combination increased arch width in these specimens but
did not materially affect the transverse cortex-to-cortex breadth of each side of the
arch itself.

SUMMARY
In a sample of mandibles having complete or nearly complete loss of dentition,
the left half of each mandible was serially sectioned. The entire perimeter of each
section was analyzed for the distribution of resorptive and depository periosteal sur-
faces, and from this information, the fields of remodeling were mapped for the man-
dible as a whole. The most common patterns of combined resorption-deposition and
the range of variations were then determined.
The over-all distribution of remodeling fields in the edentulous mandible differs
markedly from that in the young, growing mandible. In most of the edentulous
specimens, the surface of the basal bone on both the medial and lateral sides of the
corpus is of a depository nature. The overlying alveolar regions on both the lingual
and buccal sides, however, are characteristically resorptive. Significantly, the place-
ment of the reversal line between the alveolar resorptive and the basal depository
areas is much lower (i.e., at the level of the mental foramen) on the buccal side.
Except for its inferior part, the lateral side of the ramus tends to be largely re-
sorptive in character, and the posterior half of the lingual side also tends to be
resorptive. Unlike the child’s mandible, the posterior border of the ramus is resorptive,
and the posteroanterior dimension of the ramus (not the whole mandible) becomes
reduced and narrowed in conjunction with resorption along the anterior border.
However, the amount removed from the anterior ramus is actually added to the
dimension of the corpus, which becomes longer. Further, removal from the posterior
ramus border does not affect the over-all length of the mandible unless condylar
reduction is also involved. Also, over-all arch length is not decreased, because the
surface of the mental protuberance is retained as a depository type of field (or at
least does not become actively resorptive). The corpus-ramus angle (not gonial
angle) is increased in the antegonial region. Because of the opening of this angle,
over-all mandibular length as well as arch length is increased. In about half of the
specimens, arch width was not decreased, because the lateral side of the corpus is
usually of a depository nature. Notching of the anterior side of the condylar neck and
the inferior part of the anterior ramus border is associated with resorptive fields in
these regions, changes that are presumed to be a consequence of pressure contacts
made with the articular tubercle and the maxillary tuberosity, respectively, in con-
junction with a forward rotation of the whole mandible. The inferior direction of
corpus realignment relative to the basal part of the ramus also increases the notching
effect in the antegonial region, an effect augmented by the presence of the resorptive
field in the notch itself.
Certain specific variations commonly occur in several major regions of the man-
dible on both the lateral and medial sides. These remodeling variations affect the
placement of the ramus relative to the corpus, the extent of flaring of the gonial
region, the width of the arch, and the thickness of the basal part of the body.

The illustrations were prepared by Roger Posten.

Volume 36 Remodeling the edentulous mandible 693
Number 6

References
1. Enlow, D. H.: The Human Face, New York, 1968, Harper & Row, Publishers.
2. Enlow, D. H., Kuroda, T., and Lewis, A. B.: The Morphological and Morphogenetic Basis
for Craniofacial Form and Pattern, Angle Orthod. 41: 161-188, 1971.
3. Enlow, D. H.: A Handbook of Facial Growth, Philadelphia, 1975, W. B. Saunders Company.

DRS. ENLOW AND BIANCO DR. EKLUND

WEST VIRGINIA UNIVERSITY SERVICE UNIT DENTAL PROGRAM
SCHOOL OF DENTISTRY INDIAN HEALTH SERVICE
MORGANTOWN, W. VA. 26506 MANY FARMS, ARIZ. 86503

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