Trauma; PreprostheticSurgery

J. I. C a w o o d ~ a n d R. A. H o w e l l 2
A classification of the edentulous ~Maxillofacial Unit, Royal Infirmary, Chester,
UK, 2Liverpool Dental Hospital, Liverpool, UK

jaws
J. L Cawood and R. A. Howell." A classification o f the edentulous jaws. Int. J. Oral
Maxillofac. Surg. 1988; 17:232-236

Abstract. A classification of the edentulous jaws has been developed based on

a randomised cross-sectional study from a sample of 300 dried skulls. It was
noted that whilst the shape of the basalar process of the mandible and maxilla
remains relatively stable, changes in shape of the alveolar process is highly
significant in both the vertical and horizontal axes. In general, the changes of shape
of the alveolar process follows a predictable pattern• Such a classification serves
to simplify description of the residual ridge and thereby assist communication
between clinicians; aid selection of the appropriate surgical prosthodontic tech-
nique; offer an objective baseline from which to evaluate and compare different
treatment methods; and help in deciding on interceptive techniques to preserve
the alveolar process. An awareness of the pattern of resorption that takes place Key words: classification; edentulous jaws;
preprosthetic surgery.
in various parts of the edentulous jaws, enables clinicians to anticipate and avert
future problems. Accepted for publication 5 January 1988

When considering preprosthetic surgery
of the edentulous jaws, it is essential
that both the surgeon and prosthodonti-
st possess a detailed knowledge of the
changing anatomical form of the jaws,
following tooth loss.
To date, attempts to describe and
classify these changes are unsatisfac-
tory,, 2, 4, 5. They have been either too
subjective or incomplete. Several studies
refer to changes in vertical dimension
processes based on the presence of reversal
lines, which delineate the most inferior extent
to which alveolar reduction is likely to pro-
gress. This subdivision coincides with the
1A
line connecting the mental and mandibular
foramina (Figs. 1A, B). Three points S, M
and K on this line were selected. S indicates
the intersect through symphysismenti with a
horizontal line connecting the mental foram-
ina, M the mental foramen and K the mid-
2A
/ "x

occurring in the anterior region of the

edentulous mandible, but make no ref-
erence to the changes in the horizontal
dimension or to changes occurring pos-
teriorly. There is a paucity of objective
data relating to the bony changes in the
/TLv/
edentulous maxilla.
For these reasons, the authors under- 1B
took a study firstly to measure the
changes in shape of the edentulous jaws 2B
and secondly to classify these changes
if possible. iiiii!iii!iii!
] BASAL
Material and M e t h o d s

A randomised cross-sectional study of the

Greig Collection was carried out at the Royal
College of Surgeons of Edinburgh which
comprises 300 dried skulls.
Mandibular study
As demonstrated by ENLOW et al.3, there is a
subdivision between the alveolar and basalar
Fig. 1. (A) Remodeling changes (shaded) in
the mandible in relation to loss of the teeth
(after ENLOWet al.3). (B) The line connecting
S M K
mental and mandibular foramina delineates
the boundary between the alveolar process Fig. 2. Measurements of the height (A) and
and basalar process. 3 reference points S, M width (13)of the alveolar process and basalar
and K were selected. (B). process were taken at points S, M and K.
 A classification of the edentulous jaws 233

point of the line connecting the mental and
mandibular foramina.
Twelve variables were analysed, namely,
height and width of alveolar and basalar pro-
cesses at points S, M and K respectively (figs.
2A, B). The mandibles were grouped into 4
categories. Group 1 were dentate, groups 2,
3 and 4 were edentulous with moderate, se-
vere or extreme resorption respectively.
Group effect was determined by 1-factor
3A
IVIIV] S VERTICAL GROUP
• ALVEOLAR
r •
15
analysis variant. Associations between vari-
ables were measured using Pearsen's product-
moment correlation co-efficient and by
Spearman's rank-correlation co-efficient.
Results
As c a n be seen in Figs. 3 A - F , the m e a n
values o f alveolar m e a s u r e m e n t s are sig-
nificantly different between groups,
EFFECT
BASAL 3D
M HORIZONTAL
"15
[MS
whereas the m e a n value of basal
m e a s u r e m e n t s are n o t significantly dif-
ferent, see also Tables 1A, B.
Fig. 3. Differences between mean values of
mandibular measurements for groups. S ver-
tical (A); S horizontal (B); M vertical (C); M
horizontal (D); K vertical (E); K horizontal
(F).
GROUP EFFECT
• ALVEOLAR
• BASAL

P < O-OO1

GROUP ~ ~ GROUP ~ ~
3B
MM HORIZONTAL GROUP EFFECT 3E K VERTICAL GROUP EFFECT
• ALVEOLAR
• ALVEOLAR
• BASAL • BASAL
MM

15
2O
~ [ M S

5
0

p<o.oon ~ P < O.OO1

-5

GROUP 2 3 4 GROUP 2 -~ --~

3C 3F
MIV IV] VERTICAL GROUP EFFECT K HORIZONTAL GROUP EFFECT
• ALVEOLAR MM • ALVEOLAR
• BASAL • BASAL

15
15
~[Ms

~ < O-GO1 5
I
T

BROUR 2 ~ GROUP ~ ~
234 Cawood & Howell

Table 3A. Vertical maxillary alveolar Table 3D. Horizontal maxillary basalar
Maxillary study measurements (mm) (n = 30) measurement (mm) (n = 30)
O f the 4 processes o f the maxillary bone, Anterior Posterior Group I-GP GP-GP
the alveolar a n d palatal (basalar) pro- I-C GP-C mean SD mean SD
cesses are relevant to this study. The Group mean SD mean SD
1 39.60+-2.70 30.60+_ 1.82
incisive f o r a m e n (I) a n d the greater pal- 1 11.20+1.30 12.40+_0.89 2 39.23+_2.62 32.46+_2.37
atine f o r a m i n a ( G P ) are located at the 2 6.77+_2.01 10.46+_2.96 3 39.00+_2.28 33.18___1.94
j u n c t i o n o f the alveolar a n d b a s a l a r pro- 3 1.09+_ 1.45 6.46+_2.54
cesses. Figs. 4 A - D show the maxillary
alveolar a n d b a s a l a r linear m e a s u r e -
m e n t s r e c o r d e d in the vertical a n d hori-
z o n t a l axes. Table 3B. Horizontal maxillary alveolar measurements (mm) (n = 30)
T h e 11 variables s h o w n in Table 2
were analysed to d e t e r m i n e a n y changes Group IC I-B GP-C GP-B
mean SD mean SD mean SD mean SD
in s h a p e o f the b a s a l a r a n d alveolar pro-
cesses o f the maxillae. 1 10.00+2.65 10.00_+2.00 9.20_+ 1.64 13.80+_2.59
I n order to d e t e r m i n e g r o u p effect, 2 6.46_+ 1.66 7.15 +_1.52 6.92 +_1.38 10.69 -t-2.25
the maxillae were subdivided into 3 3 3.36 +_1.75 3.91 +_1.81 4.73 -t- 1.10 8.27 ___1.85
groups. G r o u p 1 were dentate, groups
2 a n d 3 were e d e n t u l o u s w i t h m o d e r a t e
a n d severe r e s o r p t i o n respectively. Table 3C. Vertical maxillary basalar measurements (mm) (n = 30)

Results Group Anterior Posterior

N-ANS ANS-I PNS-S
In general, the m e a n values o f the maxil-
mean SD mean SD mean SD
lary alveolar m e a s u r e m e n t s are signifi-
cantly different between groups; the 1 49.80-+3.27 13.20_ 1.30 25.80+0.84
m e a n values o f basal m e a s u r e m e n t s are 2 51.23+_3.24 13.15+ 1.52 25.92+_ 1.89
3 50.01 +_2.10 11.36 +_2.46 25.36 -t- 1.29
n o t (Tables 3 A - D ) .

ALWOLA.

4C ES~ ~ASAL
4A

S c

PNS ANS

C
~_ S

4B
~~i~ ALVEOLAR 4D ~ ~
[~ BASAL
[]

ct
I

..::.::~. ~.~:~$.~:':;::~:~.'.:..:,:.
•:;.:;.::.'~.::~:::::::::,.; ~:.~.-'~:::::::::.;:
;.:~
GP •~'.;g.:.:;; ..'-.~':':::::~
C C

HORIZONTAL VERTICAL

Fig. 4. Maxillary measurements (see Table

2). Vertical (A); horizontal (B); anterior (C);
B C GP GP posterior (D).
 A classification of the edentulous.jaws 235

5A Classification of the edentulous jaws

ANTERIOR MANDIBLE
Since changes in dimension of the ba-
MM salar process were not significant, re-
35
gardless of the degree of atrophy of the
alveolar process, it was possible to pro-
duce composite diagrams showing the
25
~ LABIAL most commonly observed changes in
shape of the alveolar process of the
t5
mandible (Figs. 5A, B) and the maxilla
(Figs. 6A, B) and to develop a descrip-
5 tive classification of these changes.
Class I - dentate.
5 15 MM
II III IV V VI Class II - i m m e d i a t e l y post extrac-
tion.
Class I I I - well-rounded ridge form,
5B
adequate in height and
POSTERIOR MANOIBLE width.
Class IV - knife-edge ridge form, ad-
MM equate in height and inad-
25
equate in width.
Class V flat ridge form, inadequate
in height and width.
15 ::i:i:i:i~i~:~:;~:i!ii (.1 Class VI - depressed ridge form, with
=.'~===:===:===:===: ==.========U============
~!~nl:::::::::::::::::::::::::::::::::::::
3 some basalar loss evident.

5 15
II III IV V VI
Conclusions
Fig. 5. (A) Classification of anterior mandible (anterior to mental foramina). (B) Classification
of posterior mandible (posterior to mental foramina). Arising from these morphological stud-
ies of edentulous jaws, the following
conclusions have been drawn.
(i) Basal bone does not change shape
significantly, unless subjected to harm-
6A ful local effects such as the overloading
ANTERIOR
of ill fitting dentures.
MAXILLA
(ii) Alveolar bone changes shape sig-
nificantly in both the horizontal and
MM
vertical axes.
0
(iii) In general, changes of shape of
the alveolar bone follows a predictable
pattern.
10
(iv) Pattern of bone loss varies with
sites. Anterior mandible - bone loss is
20 vertical and horizontal (from the labial
i
lO
i
o
i i i r 1 i i i i i f ~ l r l t l aspect). Posterior mandible - bone loss
II III IV V Vl is mainly vertical. Anterior maxilla -
bone loss is both vertical and horizontal
(from the labial aspect). Posterior max-
6B illa - bone loss is both vertical and hori-
zontal (from the buccal aspect).
POSTERIOR MAXILLA (v) Stage of bone loss can vary an-
teriorly and posteriorly and between
jaws.
MM

10
T
Io o
i i ~. i i i l i L i i f t i i
II III IV v vI
Fig. 6. (A) Classification of anterior maxilla (B). Classification of posterior maxilla.
236 Cawood & Howell

Such a classification serves to sim-
plify description o f the residual ridge
and thereby assist c o m m u n i c a t i o n be-
tween clinicians: aid selection o f the ap-
p r o p r i a t e s u r g i c a l / p r o s t h o d o n t i c tech-
nique; offer an objective baseline f r o m
which to evaluate and c o m p a r e different
t r e a t m e n t m e t h o d s ; help in deciding on
interceptive techniques to preserve the
alveolar process. A n awareness o f the
p a t t e r n o f resorption that takes place in
the various parts o f the e d e n t u l o u s jaw
enables clinicians to anticipate a n d av-
ert future problems.
Acknowledgements The authors acknowl-
edge the valuable assistance of Mr. C. West,
Medical Biostatician, University of Liver-
pool, Mr. R F. Wragg, Senior Registrar in
Restorative Dentistry, Glasgow Dental Hos-
pital and Miss S. L. Maudsley, Medical Sec-
retary.

References
Table 1A. Vertical mandibular alveolar measurements (mm) (n =45) 1. Atwood, D. A.: Postextraction changes
S M K in the adult mandible as illustrated by
Group mean SD mean SD mean SD microradiographs of midsagittal sections
and serial cephalometric roentgeno-
I 17.50+ 1.44 16,92_+ 1.11 7,00+ 1.03
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2 10.00_+ 1.76 10.75+ i.36 4.00+ 1.26
810-824.
3 9.21 __+0.94 7.21 ___0.73 0.50__+0.67
2. Branemark, E I., Zarb, G. & Albrekts-
4 3.40+ 1.58 2.80__ 1.21 -- 1.60+ 1.13
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Vertical Horizontal Vertical Horizontal veolar ridge atrophy: classification and
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I-B GP-B thet. Dent. 1979: 41: 90-100.
basal ANS-I I-GP PNS-S GP-GP
N-ANS Address:
J. L Cawood
N = nasion. GP = greater palatine foramen.
Maxillofacial Unit
ANS =anterior nasal spine. PNS =posterior nasal spine.
Royal Infirmary
I = incisive foramen. S =tunction of vomer with body
Chester, CH1 2AZ
C =crest of alveolar process of sphenoid bone.
UK
(adjacent to I or GP). N-ANS= anterior nasal height.
B = widest part of alveolar process S-PNS =posterior nasal height.
(adjacent to I or GP).