RESIDUAL RIDGE

RESORPTION

Presented by-
Dr. Ketaki A.Patil
1
CONTENTS
 INTRODUCTION
 DEFINITIONS
 CLASSIFICATION OF RRR
 PATHOLOGY OF RRR
 PATHOPHYSIOLOGY OF RRR
 PATHOGENESIS OF RRR
 EPIDEMIOLOGY OF RRR
 ETIOLOGY OF RRR
 CONSEQUENCES OF RRR

2
 INTRODUCTION

 Resorption is defined as loss of tissue substance

through physiologic or pathologic processes. The
tissues remaining following the extraction of the teeth
(Residual alveolar ridge) changes shape and are
reduced in size at varying rates in different individuals
and in the same individual at different times.

3
 The G.P.T. defines RRR as “A term used for the diminishing
quantity and quality of residual ridge after teeth are removed”.

 The wearing of complete dentures may have adverse effects

on the health of both oral and denture supporting tissues. The
problem of residual ridge resorption (RRR) seems to occur as a
direct sequelae of wearing complete dentures.

4
 DEFINITIONS :

 “Bone is defined as a highly vascularised, living,

constantly changing, mineralized connective tissue”.
[Gray‟s Anatomy]

 “Alveolar process may be defined as that part of the

maxilla and mandible that form and supports the sockets
of the teeth”. [Orban‟s Dental Histology]

5
 RESIDUAL ALVEOLAR RIDGE :

 “Residual alveolar ridge is that portion of the alveolar

ridge and its soft tissue covering which remains
following the removal or loss of teeth”.

[Glossary of Prosthodontic Terms]

6
 CLASSIFICATION OF RRR :
1 Branemark- bone quantity

bone quality

2 By wical and swoope

3 By kalk and baata :

Degree of alveolar bone resorption in mandible

Degree of alveolar bone resorption in maxilla

4 Atwood’s classification

5 Misch’s classification : based on bone density

7
 According to Branemark et al in 1985, ridges were
classified on the basis of bone quantity and quality by
radiographic means.

BONE QUANTITY : (Branemark)

 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
 Class E : Extreme resorption of the basal bone

8
 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 cortical bone surrounds a core
of dense trabecular bone.
 Class 4 : A thin layer of cortical bone surrounds a core
of low-density trabecular bone.

9
 BY WICAL AND SWOOPE :

 Class I : Upto one third of the original vertical height

lost.
 Class II : From one third to two thirds of the vertical
height lost.
 Class III : Two third or more of the mandibular height
lost.

10
 BY KALK AND BAATA :
Degree of alveolar bone resorption in mandible :

Class 0 : Moderate resorption ; both the genial tubercle and the

mylohyoid lines are below the level of the alveolar ridge.

 Class 1 : High degree of resorption ; the genial tubercle and the

mylohyoid are either just below the highest point of the alveolar
ridge or at the same level.

 Class 2 : Extensive resorption ; the genial tubercle is above the

level of the alveolar ridge, and the mylohyoid lines are at the same

level or above the alveolar ridge.

11
Degree of alveolar bone resorption in maxilla :

 Class 0 : Little, if any, resorption with there being a difference in

height between the lowest point on the mucosal membrane and the
highest point on the alveolar ridge. There is no flabby ridge.

 Class I : Extensive degree of resorption. The alveolar ridge is

narrow and there is little difference in height between the lowest
points on the mucosal membrane and palate and the highest point on
the alveolar ridge. There may be a flabby ridge.
12
ATWOOD’S CLASSIFICATION :

Order 1 : Pre-extraction
 Order 2 : Post-extraction
 Order 3 : High, well rounded
 Order 4 : Knife-edge
 Order 5 : Low, well round
 Order 6 : Depressed

13
MISCH’S CLASSIFICATION : Based on bone density.
 BONE -DENSITY

 D1 -Dense cortical bone.

 D2 -Thick dense to porous cortical bone on crest and

cortical tabecular bone with in.

 D3 - Thin porous cortical bone on crest and fine

trabecular bone with in

 D4 - Fine trabecular bone

 D5 - Immature, non mineralized bone

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MISCH BONE DENSITY CLASSIFICATION

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COMPOSITION OF BONE

CELLS OF BONE
Osteoprogenitor cells
Osteoblast cells.
Osteocytes
Osteoclast cells.

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ORGANIC PART – 33% - 35%

 Collagen – 88% - 90% (Type – I)

 Non collagen – 10% - 11%.
 Glycoproteins – 6% - 9% (Mono, Di, Poly
and Oligosaccharides).
 Proteoglycanes – 0.8% (sulfated and Non
sulfated)
 Sialoproteins – 0.35%
 Lipids – 0.4%

17
INORGANIC PART – 65% - 67%

 Calcium & Phosphates – 95%

(Hydroxyapatite Crystals – Ca10(Po4)6 (OH)2)
 Magnesium
 Trace elements – Nickel, Iron, Fluoride, Cadmium,
Magnesium, Zinc and Molybdenum.

18
 OSTEOBLASTS
*Uninucleated cells that synthesize both collagenous and
noncollagenous bone protein.
*They are responsible for mineralization and are derived
from a multipotent mesenchymal cell.
*They constitute a cellular layer over the forming bone
surface.

*Osteoblasts exhibit high levels of

alkaline phosphate on the outer
surface of their plasma
membranes.
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**Other enzymes that participate in their activity are
*ATPase and pyrophosphates
*Type I and type V collagen
*Several noncollagenous proteins,
*A variety of cytokines.

20
 OSTEOCYTE
*As osteoblasts secrete bone matrix, some of them become
entrapped in lacunae and are then called osteocytes.
*The number of osteoblasts that become osteocytes varies
depending on the rapidity of bone formation.
*The more rapid the formation, a more osteocytes are
present per unit volume.

21
 OSTEOCLAST
*Compared to all other bone cells and their precursors, the
multinucleated osteoclast is a much larger cell.
*They are generally seen in a cluster rather than singly.
*Osteoclast is characterized by acid phosphatase within its
cytoplasmic vesicles and vacuoles, which distinguishes it
from other giant cells and macrophages.

22
 *Osteoclast are also
rich in lysosomal
enzymes.
 Typically osteoclasts
are found against the
bone surface
occupying shallow,
hollowed out
depressions, called
Howship‟s lacunae.

23
Thus the sequence of resorptive events is considered to be
Attachment of osteoclasts to mineralized surface of bone.
Creation of a sealed acidic environment through action of
the proton pump, which demineralizes bone and exposes
the organic matrix.
Degradation of this exposed organic matrix to its
constituent amino acids by the action of released enzymes.

Uptake of mineral ions and

amino acids by the cell.

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25
 CLASSIFICATION OF BONE
1. According to density as
*Compact bone
*Trabecular bone.
2. According to bone mass
*Fine Trabeculae,
*Coarse Trabeculae,
*Porous Compacta and
*Dense Compacta.
3. Microscopically bones are composed of
*Woven bone,
*Lamellar bone,
*Bundle bone and
*Composite bone.
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WOVEN BONE
 Highly cellular.

 Formed rapidly (30-50 µm/ day or more) in response to

growth or injury.

 Low mineral content.

 Random fiber orientation and minimal strength.

 Stabilize unloaded Endosseous implants during initial healing.

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LAMELLAR BONE

 Principle load bearing tissue of adult skeleton.

 Predominant component of mature cortical and

trabecular bone.

 Formed relatively slowly (<1 µm/ day).

 Densely mineralized and highly organized matrix.

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LAMELLAR BONE

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BUNDLE BONE
 Characteristic of
ligament and tendon
attachments along
bone-forming surfaces.
 Sharpey‟s fibers from
adjacent connective
tissue insert directly
into bone.
 Bundle bone is formed
adjacent to the PDL of
natural teeth.

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COMPOSITE BONE

 High quality lamellar bone deposited on a woven

bone matrix.

 Got adequate strength for load bearing.

 Important in achieving stabilization of an implant

during the rigid integration process.

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 **Alveolar Bone forms the bony sockets of the jaw bones in which
the roots of the natural teeth are suspended by the attachment of the
periodontal ligament fibers (“Gomphosis” )

**Some alveolar bone is formed during tooth development, but the

majority of alveolar bone formation occurs during tooth eruption.

32
*The presence of alveolar bone in the jaw bones is totally
dependent on the roots of the natural teeth; without the teeth the

alveolar bone need not exist.

33
 PATHOLOGY OF RRR
 GROSS PATHOLOGY :
 Patient has expression “ My gums have shrunk “
 Basic structural change is reduction in size of bony ridge
under the mucoperiosteum

 Localized loss of bone structure

 Overlying mucoperiosteum

Excessive & redundant No redundant soft tissue

Difficult to understand

Lammie postulates 34
 LAMMIE postulates ; one factor in RRR may be a
cicatrizing mucoperiosteum that is seeking a reduced area
, resulting in pressure resorption of the underlying bone

 Longitudinal radiographic cephalometric studies have

provided excellent visualisation of gross patern of bone
loss from lateral view point

35
Careful superimposition of portions of tracings of
lateral ceph. With reduction of bone in size and shape

36
 Gross anatomic studies of dried jaw bones have shown
a wide variety of shapes and sizes of residual ridges
 A simplified method for categorizing residual ridge
form is order 1----order 6

Uses : useful clinically as well as for research purpose

: helps to differentiate various stages of RRR in pts.
37
 In dry specimens

*External cortical surface of maxilla and mandible are

uniformly smooth & crestal area of residual ridge
shows porosities and imperfections

*Bones with more severe RRR display gross porosities

of medullary bone on the crest of ridge
38
 Gross bone loss of residual ridge revealed by
superimposition of portion of two cephalometric
radiographs made 16 years apart
39
 RRR does not stop with the residual ridge but may
go well below where the apices of teeth are…

 There can be a thin cortical plate on inferior border

of mandible or virtually no maxillary alveolar
process

40
 Panoramic radiograph showing severe RRR in
both maxilla and mandible in contrast to
dentulous area that support three mandibular
teeth
41
 Radiographs of mid-saggital sections of eight
mandibles illustrating various orders of residual
ridge form Atwood DA JPD 1971
Vol.26 42
 Clinical examination of ridge form
depends on
Good judgment of clinician

 Palpation in the mouth accurately determines

underlying bone
 Lateral ceph. determines amount of bone and rate
of RRR over a period of time
 Panoramic radiographs simple & useful method
of estimating amount of RRR

43
*Original alveolar crest ht. can be predicted by
measurement of distance from inferior border of
mandible to mental foramina
Wical and Swoope

44
 MICROSCOPIC PATHOLOGY :

 Evidence of osteoclastic activity on the external surface of

crest of residual ridge
 Scalloped margins of howship‟s lacunae contain visible
osteoclasts

45
 Varying degree of inflammatory cells have found in the
areas that have appeared clinically normal all the way to
inflammed in edentulous who were either denture wearer
or non wearer

 Inflammatory cells are lymphocytes and mast cells

 Proximity of small blood vessels also found near the

resorption

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 ATWOOD DA : JPD 1963
 There is wide variation in configuration density and porosity
of not only residual ridge but also entire cross-section of
anterior mandible
 Mandibular osteoporosis occurs with
 Increased variation in density of osteons
 Increased no. of incompletely closed osteons
 Increased endosteal porosity
 Increased plugged osteons

47
 **Remodeling changes occur in the mandible that account for
the typical edentulous facial anatomy.
 The overall length of the mandible does not decrease but may in
fact increase as new bone is added to the mental protuberance,
thus accentuating the chin point.

48
 There is an anterior displacement of the mandible (protrusive
position) because of residual ridge reduction, mandibular
rotation (Change in the angulation of the body relative to the
mandibular ramus), and deposition of bone in the mental
region.

 Reduction in the residual ridges occurs in an inferior direction

in the molar and premolar areas, but in both an inferior and
lingual direction in the incisor region.

 There is generalized thinning of the anterior and posterior

aspects of the mandibular ramus.

49
 PATHOPHYSIOLOGY OF RRR
BONE REMODELLING

OSTEOBLASTS OSTEOCLASTS

BONE FORMATION BONE RESORPTION

Exceeds in case of Exceeds in case of

*GROWTH *OSTEOPOROSIS
*PDL DISEASE

50
  RESIDUAL RIDGE RESORPTION

PATHOLOGIC PHYSIOLOGIC PROCESS??

PROCESS??
Bone once lost cannot be built back Removal of tooth eliminates the
by removing causative factors reason for alveolar bone
resorption

Clinical facts :1. RRR not inevitable

2. RRR varies & can proceed far beyond alv. bone

Practical terms rate of resorption so much that patient ends up

with no cortical bone at crest of ridge
51
 Pathogenesis of RRR:
 RRR is a chronic progressive irreversible cumulative disease
which proceeds slowly over a long period of time from one
stage to next

52
  Carlson and Pearson at al
 Post extraction study of mandibular bone loss

Pts. with First 2 yrs First 5 yrs 3 to 5 yrs

Least RRR 0.75 0.4 0.13

Mean RRR 2.75 1.36 0.5

Most RRR 4.5 2.9 1.8

**measurments in mm

53
 Tallgren Atwood & Coy studied rate of residual
ridge resorption for 25 years
 Mean ratio of anterior maxillary RRR to anterior
mandibular RRR was 1:4

 RRR is more in mandible than in maxilla and reverse

can also occur

 So one must treat the „PARTICULAR PATIENT, NOT

THE AVERAGE PATIENT

54
 EPIDEMIOLOGY OF RRR :
 Methods
 Longitudinal cephalometric; time consuming and
expensive
 Panoramic methodology or radiograph

 By palpation

 There have been no large scale studies of RRR

 Longitudinal cephalometric studies of few

subjects have been done
55
 RRR occurs worldwide in
 Males and females
 Young and old
 Sickness and health
 With or without dentures
 Unrelated to primary reason for the extraction of teeth (
caries & pdl disease )
 Studies also suggest incresed knife edge
tendency (KET) in mandibular residual ridge
in women compared to men.
 KET = Change in area /Change in height

56
 Etiology of RRR :
 RRR is a multifactorial biochemical disease
caused by a combination of
 ANATOMIC FACTORS
 MECHANICAL FACTORS
 METABOLIC FACTORS Anatomic
(1998 by Leili Jahamgeri )
 PROSTHETIC FACTORS
 GENETIC FACTORS

Metabolic Mechanical

57
 1. ANATOMIC FACTORS
 RRR ≈ anatomic factors

 More bone > RRR however well rounded ridges may

resorb rapidly and knife edge ridges may remain with
little change

 Evaluate the present status of the ridge to determine

the history

 Large well rounded ridge and broad palates favorable

mechanically
58
 2. MECHANICAL FACTORS
 RRR  FORCE
DAMPING EFFECT

F
Amount
O Duration
R Frequency

C Direction &
Distribution
E

59
 Dampening effect takes place in the
mucoperiosteum, which is a viscoelastic material.

 Maxillary bone (RR) is frequently broader, flatter

and more cancellous than its mandibular
counterpart. So it is ideally constructed for the
absorption and dissipation of energy.

 Frost pointed out that the trabacule in cancellous

bone are arranged parallel to direction of
compression deformation.
60
  METABOLIC FACTORS :
RRR  BONE RESORPTION FACTORS
BONE FORMATION FACTORS
BONE RESORPTION FACTORS

LOCAL SYSTEMIC
Estrogen

-Endotoxins from dental plaque - Correct amount of Androgen

Thyroxine
-Osteoclast activating factor circulating
Vitamin-D
-Prostaglandin - Osteoporosis Flouride
-Heparin - Hypophosphetemia
-Trauma - Parathormone
- Calcitonine 61
PROSTHETIC FACTORS
 Immediate Dentures
 Overdentures

OTHERS :
 Bone loss due to unknown causes
 Age related bone loss

62
 RRR  ANATOMIC FACTORS +
BONE RESORPTION FACTORS + FORCE
BONE FORMATION FACTORS DAMPING

 In addition to the three major categories of factors

(anatomic, metabolic and mechanical), the importance
of time since extraction to the bone loss should be
emphasized by adding in an inverse ratio.
 RRR  ANATOMIC FACTORS +
BONE RESORPTION FACTORS + FORCE
BONE FORMATION FACTORS DAMPING
+ 1
TIME

63
PG‟ s AS MEDIATORS OF
RRR

64
 PG release on
mechanical,
physiologic and
pathologic stimuli.,

Neutrophilic
cells,macrophage
Localised bone
s,osteoblast,cells
resorption
of PDL

PG are local Increase in cAMP

harmones and and PG synthesis
short life span

65
 The pharmacologic effect of NSAID‟s such as
indomethacin that are known to be inhibitors of PG bio
synthesis have been investigated in order to control bone
resorption in orthodontic tooth movement and in
periodontal disease.

 It is hypothesized that osteoblasts are involved in bone

resorption by coupling with osteoclasts, because the
cellular receptor against various bone resorbing hormones
(including PG) have been found in osteoblasts but not in
osteoclasts. 66
OSTEOPOROSIS

 Osteoporosis is a systemic disease in the elderly. Osteoporosis

shows a decrease in the skeletal mass without alteration in the
chemical composition of bone.

 Loss of the spongy spicules of bone that support the weight

bearing parts of the skeleton can be seen in radiographs of
regions of the skeleton that bear heavy loads, such as the
vertebral column, epiphysis of long bones, the mandible and
the fingers. 67
OSTEOPOROSIS
 Osteoporosis is common in aging individuals, especially in
women when the estrogenic blood level is low.

 In elderly men and women, osteoporosis is caused by a

variety of factors such as calcium loss, calcium deficiency,
hormonal deficiency, change in protein nutrition and
decreased physical activity.

 Progressive loss of alveolar bone may be a manifestation of

osteoporosis

68
  Prosthodontic treatment modalities :
 1. COMPLETE DENTURES
Well fitting complete dentures
Exerts Pressure on the alveolar bone

Favourable Unfavourable

Preserves alveolar bone Resorption of alveolar bone

Campbell et al ( 1973 )
Edentulous patients wearing dentures had smaller residual
ridges as compared to those not wearing dentures

69
 WHY THERE IS MORE RESORPTION SEEN
IN MANDIBLE THAN MAXILLA ???
 1. Mandible provides a smaller surface area of
support for the dentures
 2. Amount of cancellous bone is lesser as
compared to maxilla
*Dentures help to preserve the horizontal
dimensions of residual ridge to some extent &
vertical dimensions undergo resorption especially
in mandible( 4 times)
Irreversible alveolar bone loss results from extraction regardless
of how soon a denture is provided
( Atwood DA )
70
2. OVERDENTURES :

 Distribute masticatory load between edentulous ridge

and abutment

 Transfer occlusal forces to alveolar bone through

periodontal ligament of retained roots

 Proprioceptive feedback from pdl prevents RRR

71
 3. REMOVABLE PARTIAL DENTURES :
 Loss of periodontal attachment & marginal bone loss
adjacent to abutment
Free of pdl disease
 Patient‟s
Adequate plaque control

Minimum bone loss occurs

72
4. FIXED PARTIAL DENTURES :

 Marginal bone loss is minimum & is almost same as of

uninvolved teeth

 Mean annual rate of bone loss ~ 0 mm for up to 15

years if adequate plaque control is maintained

73
5. IMPLANT SUPPORTED PROSTHESIS:
 Majority of bone loss (1-2mm ) occurs during healing and
remodelling periods
 Annual bone loss with implants is 0-0.08mm
BONE LOSS

Implant supported Implant fixed

overdenture prosthesis

Maxilla > Mandible

>
Single implant Multiple implant
prosthesis prosthesis

74
 Consequences of RRR :
 Apparent loss of sulcus width and depth.

 Displacement of muscle attachment close to the ridge.

 Loss of vertical dimension of occlusion.

 Reduction of the lower face height.

 An anterior rotation of the mandible.

 Increase in relative prognathia

 Changes in inter alveolar relationship following RRR

 Morphological changes of the alveolar bone such as sharp,

spiny uneven residual ridges.

 Location of mental formina close to the ridge crest. 75

Consequenses of residual ridge
resorption

Sharp Spiny Residual Ridge

76
Sharp Mylohyoid Ridge

77
Position Of Mental Foramen

78
Prominent Genial Tubercles

79
Paraesthesia From Dehiscent
Mandibular Canal

80
Loss of Basal Bone

81
Decrease Height of Supporting Bone
 Reduction of
residual ridge height
in

82
Esthetic Problem Of RRR
 Prognathic appearance
 Thinnig of lips
 Deepening of nasolabial
groove
 Decrease in facial height
 Increase in columella
filtrum angle
 Loss of tone in muscles of
facial expressions

83
 PREVENTION OF RRR
 Preventing loss of teeth

 Correct diagnosis & management of etiologic factors

 Correct hormonal & nutritional deficiencies if any.

 Remove dentures for atleast 8-12 hours for tissue rest

 Bitting with fork & knife i.e placing small masses of

food over posterior teeth ( Heartwell )

84
 Review of Literature

John O. Neufeld 1958

did a microscopic study of mandibular specimens,
showed that

· The trabecular pattern of the body of the mandible, upon the

loss of the teeth and the remains of the alveolar process, is
reorganized in a more or less random manner.
· In some of the specimens studied, the trabecular pattern will
rearrange itself in such a manner that it would indicate resistance to
stresses applied.
 John O. Neufeld. Changes in the trabecular pattern of the mandible following
the loss of teeth. J Prosthet Dent. 1958;8; 685-697
85
  Wical and Swoope in 1974 described a method of
estimating the severity of mandibular bone resorption by
using the mental foramen and the inferior border of the
mandible, as they appear in panoramic radiographs, as
reference points.

Kenneth E. Wical and Charles C. Swoope. Studies of residual ridge resorption. Uses panaromic
radiographs for evaluation and classification of mandibular resorption. JPD;1974;32;

86
  Julian B. Woelfel et al in 1978 did study on mandibular
ridge resorption with different posterior occlusal forms
( 00, 220 and 330 cusps)
 They found that
 After 5 year of placement of dentures the reduction of
occlusal vertical dimension (nasion to menton) was
 3.6mm for the nonanatomic group
 3.2mm for the semianatomic group and
 2.8mm for the anatomic group.

Julian B. Woelfel, Chester M. Winter and Takayoshi Igarashi. Five-year cephalometric study of
mandibular ridge resorption with different poosterior occlusal forms. JPD;1978;39;602

87
 Don G Garver et al in 1980 studied the value of
vital root retention in the preservation of residual
ridge resorption.
 They concluded that
 Vital root retention in humans appears to be valid
means of retaining residual bony ridge tissues to a
greater degree than when patients rendered totally
edentulous.

Don G. Garver and Robert K. Fenster. Vital root retention in humans: a final report. JPD
1980;43;368
88
References

 John O. Neufeld. Changes in the trabecular pattern of

the mandible following the loss of teeth. J Prosthet Dent.
1958;8; 685-697
 Kenneth E. Wical and Charles C. Swoope. Studies of
residual ridge resorption. Uses panaromic radiographs for
evaluation and classification of mandibular resorption.
JPD;1974;32;
 Julian B. Woelfel, Chester M. Winter and Takayoshi
Igarashi. Five-year cephalometric study of mandibular
ridge resorption with different poosterior occlusal forms.
JPD;1978;39;602

89
 Don G. Garver and Robert K. Fenster. Vital root retention
in humans: a final report. JPD 1980;43;368
 Qiu-Fei Xie and Anja Ainamo. Correlation of gonial
angle size with cortical thickness, height of the mandibular
residual body, and duration of edentulism.
JPD;2004;91;477
 Atwood DA: Some clinical factors related to rate of
resorption of residual ridges. J Prosthet Dent 2001;86:119-
125.
 Winkler S : Essentials of complete denture prosthodontics.
2nd edition,2000.
 Boucher CO : Prosthodontic treatment for edentulous
patients. 12th edition,2004.

90
Acknowledgements

 Dr Ashok Patil
 Dr Premraj Jadhav
 Dr Abhijit Deshpande
 Dr Shivsagar Tewary
 Dr Sharad Acharya
 Dr Karuna Pawashe
 Dr. Digvijaya Patil

91
THANK YOU

92
Management
 1)Treatment of systemic factors involved in RRR
 2)Prosthodontic management
 a) Methods to improve denture foundation
 b) Design of the dentures
 c) Impression procedures
 d )Other options ;
 Overdentures
 Submerged roots
 Hollow dentures
 Metal based dentures
 3)Surgical management
93
 1)Treatment of systemic factors involved in RRR

 Role of systemic disease as an etiological factor

in gross alveolar resorption must be considered
 Systemic conditions like osteoporosis, hormonal
imbalance and dietary deficiencies plays an
important role in RRR
 Prosthodontist should always consider the
possibility of systemic cause for gross alveolar
resorption

94
A)METHODS TO IMPROVE DENTURE
FOUNDATION

 Use of temporary soft liner

 Regular finger massage of denture bearing mucosa

 Rest for denture supporting tissues

 Correction of old prosthesis to restore VD

 Good nutrition especially for geriatric patients

 Conditioning of patients musculature by jaw exercises , co-

ordination &

 Preparing the patient psychologically 95

 A course of treatment with tissue conditioning
materials is often indicated.
 These materials allow deformed tissues to resume
their normal shape
 Abraded artificial teeth cause loss of facial height

 Failure to carry out such corrective therapy can result

in continuing distortion of oral tissues by dentures

96
 B) DESIGN OF THE DENTURE ;
 a)Broad area of coverage to decrease force per unit
area ( SNOW SHOE EFFECT )
 b)Decrease number of dental units & decreased
bucco-lingual width of teeth ( decreased force to
penetrate bolous of food )
 c)Avoidance of inclined planes ( to minimise
dislodgement of denture & shear forces )
 d) Centralization of occlusal contacts ( to increase
stability & maximise compressive forces )
 e)provision of adequate tongue room & adequate
inter-occlusal distance
97
 f) occlusal pattern ;
 Anatomic teeth with compensating curves
 Careful setting & selective grinding to minimise
lateral stresses

98
 g) Muscular Control ( Neutral Zone )
 Gardette (1800 ) first noted potential
of muscular forces in denture control
 Fish (1933) introduced concept of denture control
 The secondary supporting surface i.e polished surface
should have their shape determined by oral musculature
( neutral zone )
 h) Tooth Material
 Acrylic vs Porcelein
 The property of transmission of impact forces is more
important than wear resistance when considering health
of alveolar ridges

99
 Acrylic teeth

 Cushioning effect

 Absorbs more forces than porcelein teeth

PLUS
 Denture base material acrylic or metal

100
 C ) IMPRESSION PROCEDURES ;
 Bernard Levin ---Primary impression made with
alginate and less water ( 25 % )
 Mac – Cold & Tyson ( BDJ 1997 )---Use of
admixed technique for impressions ( 3:7 )
 Functional reline technique---use of open and close
mouth procedures
 Procedures for severely atrophied mandible (JPD
1993 ; 73 : 574 )--- peripheral borders are developed
functionally with tissue conditioning material and
final impression is taken with polysulphide
impression material

101
 This technique involves making impressions of
soft structures of mouth adjacent to buccal ,
labial , lingual & palatal surfaces of dentures
& incorporating the resulting extensions into
denture construction.

MATERIAL USED – Flange Wax

102
103
104
 ADVANTAGES
Area of intimate contact
of the denture bases with
underlying adjacent
structures is increased by
flanges.
Improvement in retention
,stability & masticatory
efficiency.

105
 The neutral zone is an area where displacing
forces of lips , cheeks, & tongue are in balance. It is
in this zone that the natural dentitions lie & this is
where the artificial teeth should be positioned.

MATERIAL USED FOR SHAPING NEUTRAL

ZONE -- modelling plastic impression
compound

106
 METHOD
Primary impression were made of
upper & lower arch . Maxillary
secondary impression was made
& wax rim is prepared on upper
trial denture base .

A special tray of acrylic was

made on lower ridge, with spurs
or fins projecting upward.

107
The lower special tray with the
softened low fusing compound
was placed in the patients mouth

This tray was adjusted

Talk , swallow, drink some water.

After 5-10 min , the set
impression was removed .

The internal & external group of

muscles molded the low fusing
compound into state of neutral
balance.

108
After a tentative vertical
dimension & centric relation
have been established .

Final impression was made

with a closed mouth
procedure.

The occlusal vertical

dimension & centric relation
was determined after final
impression was made.

109
Place plaster or silicone putty index
around the model and impression.

Remove the NZ impression from the

base plate. Replace the index.

Pour wax into the remaining space.

Set up the teeth following the index.

External surface impression was

made using zinc-oxide eugenol
impression paste.

110
ADVANTAGES
Improved stability and retention.
Posterior teeth were correctly positioned & allow sufficient tongue
space.
Good esthetics due to facial support.

DISADVANTAGES
Extra clinical step and increase laboratory cost.
Requires good communication with the technician

TWO OBJECTIVES
Teeth will not interfere with the normal muscle function
Forces exerted by the musculature against the dentures are more
favorable for stability and retention.

111
 In the patients with ridge resorption , muscle attachments are
located near the crest of the residual ridge & consequently , the
dislocating effect of muscles on the denture is great. For this
reason , the range of muscle action , as well as space into which
denture can be extended without dislocation , must be accurately
located in the impression. Such impressions can be made by
means of dynamic methods.

112
Stops are made of a
thermoplastic
impression material or
green stick modelling
compound inside of
impression tray.

113
 Mandibular rests are placed
on occlusal surface in molar
region . A ridge of self cure
acrylic resin.

While the thermoplastic

material is still soft , the tray
is placed in position on
lower ridge in the mouth &
patient is asked to close the
jaws slowly .

The upper residual ridge will

form an impression in soft
thermoplastic material at a
height corresponding to rest
position of mandible.
114
 IMPRESSION METHOD
Irreversible hydrocolloid is placed directly into the mouth .
The sublingual space should be completely filled with
impression material .

A small portion is then placed in the impression tray & the

tray is placed in the patients mouth. The tray is pressed
until the stops are firmly seated on the residual ridge . Then
the patient is asked to close his mouth slowly until the
mandibular rests have obtained firm contact with maxilla.

115
Swallow three to four times at 10 second interval. The
patient should forcefully protrude the lip & vigorously
contract the buccinators muscle in between the
swallows.

After the final impression material has set ,the tray is

removed from the mouth & cast is poured
immediately.
116
Procedure is repeated until
denture borders are completely
covered by impression material.

The borders of the denture base

from a dynamic impression are
longer lingually & bucally in
relation to amount of extension
obtained from conventional
impression

117
 It has the following advantages:

 can be easily controlled to gain maximum coverage

 corrected readily

 used to accurately determine the extent of the

muccobuccal reflections
J Prosthet dent 2009; 101:279-282
118
 Used to direct pressure to the load-bearing areas, specifically,
the buccal shelves and the slopes of residual ridges in the
mandible

 The low viscosity elastomeric impression material is

advantageous because it creates minimal pressure, produces
accurate details, does not distort easily, and is easy to handle.

119
Preliminary cast

120
Border molded tray with window opening

121
Tray with fluid wax impression of slopes and
periphery

122
Application of vinyl polysiloxane impression
material

123
Boxing of impression with plaster and pumice mix

124
Definitive cast

125
WINKELER‟S METHOD

 Winkler describes a technique, which uses tissue

conditioners. An over extended primary impression of
alginate is made. Occlusal rims are constructed and the
borders are adjusted so that the lingual flange and
sublingual crescent area are in harmony with the resulting
and active phases of the floor of the mouth by an open and
closed mouth technique

126
3 applications o f conditioning material are used – each
application approximately 8 –10 minutes. The third and
final wash is made with a light bodied material. This
technique results in an impression that has a tissue placing
effect, with relatively thick buccal, lingual and sublingual
crescent area borders. Miller used mouth – temperature
waxes instead of tissue conditioners.

127
 Other options
 Overdentures :distribute masticatory load b/w
edentulous ridge and abutment
 Rate of bone loss 0.8 mm in first year
 Submerged roots : vital or non-vital
 prevents resorption of ridges
 Hollow dentures; ( JPD 1988 ; 59 :4)
 Used in advanced atrophy of maxilla with adequate
interocclusal distance
 Double flask technique of Challian & barnett‟s is used for
maxilla ( weight reduction 25 % )
 Holtz technique with modifications for mandible

128
 Metal based dentures ; ( JPD 1987 ;57:6 )
 Metal based denture with soft liner is advocated
in patients with severely atrophic residual ridges
 Metal base provides
 Weight necessary to facilitate retention
 Maintain Adequate strength with modest extensions
 The soft liner accomodates ridge irregularities
and changes

129
 Dietary guidelines for patients at risk of losing
bone
Maintain a high daily calcium intake

 Obtain four servings of low fat dairy foods or obtain

equivalent amounts of calcium daily
 Take calcium supplements if dietary intake is low
Choose calcium citrate maleate if patient has
achlorhydria.
 If lactose intolerant, treat milk with lactase tablets or
drops

130
 Dietary guidelines for patients at risk of losing
bone

 Prevent negative calcium balance

 Limit daily alcohol and caffeine intake
 Consume about 6 ounces of protein from meat, poultry
and fish
 Use small amounts of processed foods high in sodium

131
 Dietary guidelines for patients at risk of losing
bone

 Obtain 4000 I.U of Vitamin D daily

 Spend 15 minutes in the sun 3 times a week

 Choose a multivitamin or calcium supplement that
contains 4000 I.U of Vitamin D.

132
 •Nutrient •Effect on metabolism

• Calcium •Increases
bone mass, decreases rate of bone loss in post
menopausal women

• Vitamin D •Increases intestinal absorption of calcium, decreases bone

resorption.

• Phosphorus •High intake may increase calcium urinary loss

• Sodium •High intake increases urinary calcium losses

• Fluoride •Stimulate osteoblasts, increases trabecular bone mass.

• Caffeine •High intake increases calcium urinary losses

• Alcohol •High intake accelerates menopause, toxic effects on

osteoblasts, increased calcium urinary losses

133
 Surgical treatment

 Preprosthetic surgery includes ;

 Ridge preservation procedure as a preventive

measure

 Corrective or recontouring procedures of the defects

and abnormalities

 Ridge extension procedures

 Relative methods e.g., sulcus extension (vestibuloplasty)
 Absolute methods e.g., ridge augmentation method

134
 Surgical treatment

 Reconstruction methods like correction of abnormal ridge

relationship

 Provision of accessory undercuts

 Creating favourable undercuts

 Modified denture construction procedure e.g., immediate

denture where construction of the denture proceeds surgery

135
 Ridge augmentation

 It is aimed at :

 Increase in the ridge height and width providing a

large denture bearing area ,

 Protection of neuro vascular bundles

 Restoration of proper maxillomandibular arch

relationship.

136
 Ridge augmentation has been tried with:
 Bone transplants

 Autogenous and homogenous cartilage

 Hydroxyapatite porous replamine form

 Acrylic implants.

 Tri calcium phoshpate

137
 IMPLANTS ;
 ADVANCED RRR: Surgical management ( IJP
1993)
 With introduction of osseointegration by Branemark
reconsrtuction of advanced RRR has become a
successful procedure

 The various problems associated with RRR and

stability of removable soft tissue borne dentures have
aroused interest in dental implantology to provide
stable mechanical support to the dental prosthesis.

138
 IMPLANT SUPPORTED PROSTHESIS.
 Maintenance of alveolar bone
 Maintenance of occlusal vertical dimension.
 Height of alveolar bone is found to be maintained as long as
the implant remains healthy.
 Improved psychological health.
 Regained proprioception.
 Increased stability, retention and phonetics.

139
 Maintenance of structure and function of muscles of
mastication and facial expression.
 Immune to caries.
 Overall volume of bone is maintained.
 Efficiency to take up stress and strain.
 There is 20 fold decrease in the loss of structure with implants
when compared with resorption that occurs with removable
prosthesis.

140
 CONCLUSION :

 The etiology of residual ridge resorption is a subtle

combination of local and systemic factors, but the
exact processes involved are poorly understood.

 There is no reliable clinical measurement, which might

predict the future rate of alveolar ridge resorption in a
particular edentulous patient.

141
 The best possible method is to preserve as many
teeth or roots, as possible, followed by over-dentures
which may act as effective means of preserving
adjacent alveolar bone.

 The use of endosseous implants to support fixed or

removable prostheses has been shown to preserve
adjacent remaining alveolar bone. But as with natural
teeth, implants are not immune to bone loss.

142
 Still more is needed to research RRR and to find
better methods of prevention or control of the disease
to provide best possible oral health care or millions
of edentulous patients.

143
 REFERENCES

1) Zarb-Bolender, Twelth edition Text book of complete dentures –

Arthur.O.Rahn,Charles M.Heartwell Fifth edition
2) Essentials of complete denture prosthodontics -Sheldon
Winkler, Second edition
3) Flange Technique : An anatomic & physiologic approach to
increase retention, function, comfort, & appearance of dentures.
JPD 1966:16; 394-413.
4) Dynamic Impression Methods JPD nov-dec 1965.
5) Modified fluid wax impression for a severly resorbed
edentulous mandibular ridge. JPD 2009;101:279-282
144
 The neutral zone in complete dentures J Prosthet Dent
2006;95:93-101.
 Using the neutral zone to obtain maxillomandibular
relationship records for complete denture patients J
Prosthet Dent 2001;85:621-3
 Impression making J. F. McCord,1 and A. A. Grant,2
BDJ, Vol 188, No. 9, MAY 13 2000
 Modified fluid wax impression technique for a severely
resorbed edentulous mandibular ridge. J Prosthet Dent
2009;101:279-282

145
Acknowledgements

 Dr Ashok Patil
 Dr Premraj Jadhav
 Dr Abhijit Deshpande
 Dr Shivsagar Tewary
 Dr Sharad Acharya
 Dr Karuna Pawashe
 Dr. Digvijaya Patil

146
THANK YOU

147